Provider Demographics
NPI:1760682793
Name:IMPERIAL VALLEY PODIATRY ASSOCIATES INC
Entity Type:Organization
Organization Name:IMPERIAL VALLEY PODIATRY ASSOCIATES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CYRIL
Authorized Official - Middle Name:M
Authorized Official - Last Name:GOSTICH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:760-337-2800
Mailing Address - Street 1:IMPERIAL VALLEY PODIATRY ASSOCIATES INC
Mailing Address - Street 2:P.O.BOX 650
Mailing Address - City:EL CENTRO
Mailing Address - State:CA
Mailing Address - Zip Code:92244-0650
Mailing Address - Country:US
Mailing Address - Phone:760-337-2800
Mailing Address - Fax:760-337-9099
Practice Address - Street 1:1503 N IMPERIAL AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-6301
Practice Address - Country:US
Practice Address - Phone:760-337-2800
Practice Address - Fax:760-337-9099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-18
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3744213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRE001481Medicaid
CAGRE001481Medicaid
CAW16770Medicare PIN
CA5913220001Medicare NSC