Provider Demographics
NPI:1295909265
Name:FOOT SPECIALISTS OF NORTH CONUNTY PODIATRY GROUP,INC.
Entity type:Organization
Organization Name:FOOT SPECIALISTS OF NORTH CONUNTY PODIATRY GROUP,INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/SECRETARY
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:
Authorized Official - Last Name:VANDERHEYDEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:760-724-5560
Mailing Address - Street 1:1011 S SANTA FE AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92083-6917
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1011 S SANTA FE AVE
Practice Address - Street 2:SUITE F
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92083-6917
Practice Address - Country:US
Practice Address - Phone:760-724-5560
Practice Address - Fax:760-724-6052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-21
Last Update Date:2008-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE-3486213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E-34860Medicaid