Provider Demographics
NPI:1184737546
Name:EAST VALLEY FOOTCARE PLLC
Entity type:Organization
Organization Name:EAST VALLEY FOOTCARE PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:480-357-4400
Mailing Address - Street 1:6104 E BROWN RD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85205-4953
Mailing Address - Country:US
Mailing Address - Phone:480-357-4400
Mailing Address - Fax:480-807-0800
Practice Address - Street 1:6104 E BROWN RD
Practice Address - Street 2:SUITE 102
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85205-4953
Practice Address - Country:US
Practice Address - Phone:480-357-4400
Practice Address - Fax:480-807-0800
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-17
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ322213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ480032936OtherRR MEDICARE
AZ480032937OtherRAILROAD MEDICARE
AZ480032937OtherRAILROAD MEDICARE
AZZ68001Medicare PIN