Provider Demographics
NPI:1790846020
Name:THE DOCTORS SHOE STORE
Entity Type:Organization
Organization Name:THE DOCTORS SHOE STORE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RUSSELL
Authorized Official - Middle Name:MILES
Authorized Official - Last Name:BLATSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:772-380-9998
Mailing Address - Street 1:1228 SE PORT ST LUCIE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-5330
Mailing Address - Country:US
Mailing Address - Phone:772-380-9998
Mailing Address - Fax:
Practice Address - Street 1:1228 SE PORT ST LUCIE BLVD
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-5330
Practice Address - Country:US
Practice Address - Phone:772-380-9998
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL121954071029341332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLR9845OtherBCBS
FL5263490001Medicare ID - Type Unspecified