Provider Demographics
NPI:1801868013
Name:FOOT SPECIALISTS OF NORTHRIDGE - PODIATRY GROUP
Entity Type:Organization
Organization Name:FOOT SPECIALISTS OF NORTHRIDGE - PODIATRY GROUP
Other - Org Name:FOOT SPECIALIST OF THE CONEJO VALLEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:STEFAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FELDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-706-1924
Mailing Address - Street 1:10515 BALBOA BLVD.
Mailing Address - Street 2:SUITE 140
Mailing Address - City:GRANADA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91344
Mailing Address - Country:US
Mailing Address - Phone:818-363-9900
Mailing Address - Fax:818-363-9915
Practice Address - Street 1:32144 AGOURA RD.
Practice Address - Street 2:SUITE 105
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361
Practice Address - Country:US
Practice Address - Phone:818-706-1924
Practice Address - Fax:818-706-1369
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FOOT SPECIALISTS OF NORTHRIDGE - PODIATRY GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-02-02
Last Update Date:2015-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE-2430213ES0103X
CAE-2279213ES0103X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWE5943BMedicare PIN
CAGR0000442Medicaid
CA1172770002Medicare NSC