Provider Demographics
NPI:1710258017
Name:COAST TO COAST PODIATRY
Entity Type:Organization
Organization Name:COAST TO COAST PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:AYODELE
Authorized Official - Last Name:OTIKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-708-7668
Mailing Address - Street 1:18740 VENTURA BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-6353
Mailing Address - Country:US
Mailing Address - Phone:818-836-2475
Mailing Address - Fax:818-708-9668
Practice Address - Street 1:18740 VENTURA BLVD STE 102
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-6353
Practice Address - Country:US
Practice Address - Phone:818-708-7668
Practice Address - Fax:818-708-9668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-18
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE4159OtherLICENSE NUMBER