Provider Demographics
NPI:1932144417
Name:SOUTHAMPTON PODIATRY ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHAMPTON PODIATRY ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLEMENT
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:D'ANGELO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:215-357-3668
Mailing Address - Street 1:981 ROZEL AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-4127
Mailing Address - Country:US
Mailing Address - Phone:215-357-3668
Mailing Address - Fax:
Practice Address - Street 1:981 ROZEL AVE
Practice Address - Street 2:
Practice Address - City:SOUTHAMPTON
Practice Address - State:PA
Practice Address - Zip Code:18966-4127
Practice Address - Country:US
Practice Address - Phone:215-357-3668
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-18
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0009770320002Medicaid
PA125780OtherBLUE SHIELD
PA0023131000OtherIDEPEN. BC/KEYSTONE,PC
PA0023131000OtherIDEPEN. BC/KEYSTONE,PC