Provider Demographics
NPI:1821113481
Name:MIDWAY PODIATRY CLINIC INC
Entity Type:Organization
Organization Name:MIDWAY PODIATRY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PARIS
Authorized Official - Middle Name:
Authorized Official - Last Name:SERVATJOO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:818-995-4040
Mailing Address - Street 1:7217 CANBY AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-3003
Mailing Address - Country:US
Mailing Address - Phone:818-995-4040
Mailing Address - Fax:818-996-3219
Practice Address - Street 1:7217 CANBY AVE
Practice Address - Street 2:
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-3003
Practice Address - Country:US
Practice Address - Phone:818-995-4040
Practice Address - Fax:818-996-3219
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-20
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3494213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT11704Medicare UPIN
CAWE11635Medicare PIN