Provider Demographics
NPI:1972645398
Name:EAST BOCA PODIATRY PA
Entity Type:Organization
Organization Name:EAST BOCA PODIATRY PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BARRY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:RUDIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:561-416-1196
Mailing Address - Street 1:5458 TOWN CENTER RD
Mailing Address - Street 2:SUITE 17
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33486-1089
Mailing Address - Country:US
Mailing Address - Phone:561-416-1196
Mailing Address - Fax:566-141-6182
Practice Address - Street 1:5458 TOWN CENTER RD
Practice Address - Street 2:SUITE 17
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33486-1089
Practice Address - Country:US
Practice Address - Phone:561-416-1196
Practice Address - Fax:566-141-6182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO998213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLK0239Medicare ID - Type Unspecified
FLT50840Medicare UPIN