Provider Demographics
NPI:1912194085
Name:POCATELLO PODIATRY ASSOCIATES PA
Entity Type:Organization
Organization Name:POCATELLO PODIATRY ASSOCIATES PA
Other - Org Name:AMBULATORY FOOT AND ANKLE CLINIC
Other - Org Type:Other Name
Authorized Official - Title/Position:CREDENTIALING
Authorized Official - Prefix:
Authorized Official - First Name:KOREE
Authorized Official - Middle Name:
Authorized Official - Last Name:GODFREY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:208-233-4355
Mailing Address - Street 1:1555 E CLARK ST
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4133
Mailing Address - Country:US
Mailing Address - Phone:208-233-4355
Mailing Address - Fax:208-233-7198
Practice Address - Street 1:1555 E CLARK ST
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-4133
Practice Address - Country:US
Practice Address - Phone:208-233-4355
Practice Address - Fax:208-233-7198
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-02
Last Update Date:2021-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDP-82213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID004400900Medicaid
ID004400900Medicaid
ID0282100001Medicare NSC