Provider Demographics
NPI:1639472301
Name:BERKELEY FOOT CLINIC PODIATRY GROUP A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:BERKELEY FOOT CLINIC PODIATRY GROUP A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/ OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:E
Authorized Official - Last Name:WOLPA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:510-849-3800
Mailing Address - Street 1:3000 COLBY ST STE 104
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2090
Mailing Address - Country:US
Mailing Address - Phone:510-849-3800
Mailing Address - Fax:510-849-3810
Practice Address - Street 1:3000 COLBY ST STE 104
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2090
Practice Address - Country:US
Practice Address - Phone:510-849-3800
Practice Address - Fax:510-849-3810
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-17
Last Update Date:2014-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE1852305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE18520Medicare PIN