Provider Demographics
NPI:1942432505
Name:CUPERTINO PODIATRY INC.
Entity Type:Organization
Organization Name:CUPERTINO PODIATRY INC.
Other - Org Name:CUPERTINO PODIATRY, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CMO
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:REYZELMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:415-292-0638
Mailing Address - Street 1:15100 LOS GATOS BLVD STE 4
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2028
Mailing Address - Country:US
Mailing Address - Phone:408-358-6234
Mailing Address - Fax:408-358-3389
Practice Address - Street 1:10353 TORRE AVE
Practice Address - Street 2:SUITE C
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-3217
Practice Address - Country:US
Practice Address - Phone:408-446-5811
Practice Address - Fax:408-996-1637
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PNC MANAGEMENT LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-17
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4260213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1942432505Medicaid
CACD479AMedicaid