Provider Demographics
NPI:1861665770
Name:ACTIVE FOOT CARE, INC.
Entity Type:Organization
Organization Name:ACTIVE FOOT CARE, INC.
Other - Org Name:JALAL K SIDANI DPM
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JALAL
Authorized Official - Middle Name:K
Authorized Official - Last Name:SIDANI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:850-769-1055
Mailing Address - Street 1:2563 HUNTCLIFF LANE
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4902
Mailing Address - Country:US
Mailing Address - Phone:850-769-1055
Mailing Address - Fax:850-769-1434
Practice Address - Street 1:2563 HUNTCLIFF LANE
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4902
Practice Address - Country:US
Practice Address - Phone:850-769-1055
Practice Address - Fax:850-769-1434
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ACTIVE FOOT CARE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-04-11
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP02326213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390159900Medicaid
FLU26976Medicare UPIN
FL390159900Medicaid
FL65306Medicare PIN