Provider Demographics
NPI:1356625297
Name:ST PETERSBURG DIABETIC & ARTHRITIC FOOT CENTER PA
Entity type:Organization
Organization Name:ST PETERSBURG DIABETIC & ARTHRITIC FOOT CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DARALL
Authorized Official - Middle Name:J
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:727-321-8806
Mailing Address - Street 1:4200 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33711-1140
Mailing Address - Country:US
Mailing Address - Phone:727-321-8806
Mailing Address - Fax:727-321-6838
Practice Address - Street 1:4200 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33711-1140
Practice Address - Country:US
Practice Address - Phone:727-321-8806
Practice Address - Fax:727-321-6838
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-10
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL5192590001Medicare NSC