Provider Demographics
NPI:1760151088
Name:PODIATRY GROUP LLC
Entity Type:Organization
Organization Name:PODIATRY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:BAMIDELE
Authorized Official - Middle Name:O
Authorized Official - Last Name:OLUPONA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:202-321-8812
Mailing Address - Street 1:2400 SW 69TH AVENUE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33155
Mailing Address - Country:US
Mailing Address - Phone:305-450-1757
Mailing Address - Fax:305-265-4844
Practice Address - Street 1:2400 SW 69TH AVENUE
Practice Address - Street 2:SUITE 140
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155
Practice Address - Country:US
Practice Address - Phone:305-450-1757
Practice Address - Fax:305-265-4844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-09
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty