Provider Demographics
NPI:1962450833
Name:DEGRANDMONT, ALLEN JEROME (DPM)
Entity Type:Individual
Prefix:DR
First Name:ALLEN
Middle Name:JEROME
Last Name:DEGRANDMONT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:188 E 17TH ST
Mailing Address - Street 2:SUITE #101
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92627-3763
Mailing Address - Country:US
Mailing Address - Phone:949-646-7110
Mailing Address - Fax:949-646-3957
Practice Address - Street 1:188 E 17TH ST
Practice Address - Street 2:SUITE #101
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3763
Practice Address - Country:US
Practice Address - Phone:949-646-7110
Practice Address - Fax:949-646-3957
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1767213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT11060Medicare UPIN