Provider Demographics
NPI:1790864619
Name:VALLEY FOOT & ANKLE, PC
Entity Type:Organization
Organization Name:VALLEY FOOT & ANKLE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTITIONER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRANDON
Authorized Official - Middle Name:DEAN
Authorized Official - Last Name:WILDE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:208-232-0006
Mailing Address - Street 1:1455 BENCH RD STE B
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-5084
Mailing Address - Country:US
Mailing Address - Phone:208-232-0006
Mailing Address - Fax:208-233-8771
Practice Address - Street 1:1455 BENCH RD
Practice Address - Street 2:SUITE B
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201
Practice Address - Country:US
Practice Address - Phone:208-232-0006
Practice Address - Fax:208-233-8771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2017-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP92213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDT44251Medicare UPIN
ID5051660001Medicare NSC
IDU73210Medicare UPIN