Provider Demographics
NPI:1639125362
Name:DALY CITY PODIATRY GROUP
Entity type:Organization
Organization Name:DALY CITY PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MISS
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:MENESES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:650-755-3338
Mailing Address - Street 1:1800 SULLIVAN AVE
Mailing Address - Street 2:SUITE 106
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-2228
Mailing Address - Country:US
Mailing Address - Phone:650-755-3338
Mailing Address - Fax:650-755-7892
Practice Address - Street 1:1800 SULLIVAN AVE
Practice Address - Street 2:SUITE 106
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94015-2228
Practice Address - Country:US
Practice Address - Phone:650-755-3338
Practice Address - Fax:650-755-7892
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRE001340Medicaid
CAZZZ18471ZMedicare PIN
CA4828010001Medicare NSC