Provider Demographics
NPI:1457567570
Name:MARK T KIDON DPM FACFAS A PODIATRY CORPORATION
Entity Type:Organization
Organization Name:MARK T KIDON DPM FACFAS A PODIATRY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:T
Authorized Official - Last Name:KIDON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:626-799-1194
Mailing Address - Street 1:10 CONGRESS ST
Mailing Address - Street 2:STE 410
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91105-3045
Mailing Address - Country:US
Mailing Address - Phone:626-799-1194
Mailing Address - Fax:626-449-9862
Practice Address - Street 1:10 CONGRESS ST
Practice Address - Street 2:STE 410
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3045
Practice Address - Country:US
Practice Address - Phone:626-799-1194
Practice Address - Fax:626-449-9862
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-15
Last Update Date:2018-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3196213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E31960Medicaid
CA5847580001Medicare NSC
CAT19082Medicare UPIN
CAW19694Medicare UPIN