Provider Demographics
NPI:1851522254
Name:PROVIDENCE FOOT AND ANKLE CENTER
Entity Type:Organization
Organization Name:PROVIDENCE FOOT AND ANKLE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:SANG-WOOK
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:323-732-7551
Mailing Address - Street 1:1417 STEIN STRAUSS ST
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-2159
Mailing Address - Country:US
Mailing Address - Phone:714-797-3668
Mailing Address - Fax:
Practice Address - Street 1:3130 W OLYMPIC BLVD
Practice Address - Street 2:SUITE 170
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2484
Practice Address - Country:US
Practice Address - Phone:323-732-7551
Practice Address - Fax:323-732-7829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-08-03
Last Update Date:2020-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4031261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACE810ZOtherPTAN
CAU64736Medicare UPIN
CACE810ZOtherPTAN
CA1104825033Medicare PIN