Provider Demographics
NPI:1396929774
Name:ORANGE COUNTY FOOT & ANKLE GROUP, INC.
Entity type:Organization
Organization Name:ORANGE COUNTY FOOT & ANKLE GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:IAN
Authorized Official - Last Name:BENNETT
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:714-832-0271
Mailing Address - Street 1:17400 IRVINE BLVD
Mailing Address - Street 2:SUITE J
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3030
Mailing Address - Country:US
Mailing Address - Phone:714-832-0271
Mailing Address - Fax:714-832-0272
Practice Address - Street 1:17400 IRVINE BLVD
Practice Address - Street 2:SUITE J
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-3030
Practice Address - Country:US
Practice Address - Phone:714-832-0271
Practice Address - Fax:714-832-0272
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-21
Last Update Date:2007-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4301213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW17894AMedicare PIN