Provider Demographics
NPI:1649456229
Name:MARICOPA PODIATRY CORPORATION
Entity type:Organization
Organization Name:MARICOPA PODIATRY CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:THARESH
Authorized Official - Middle Name:
Authorized Official - Last Name:UDUPA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:623-214-3335
Mailing Address - Street 1:PO BOX 9350
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374-0139
Mailing Address - Country:US
Mailing Address - Phone:623-214-3335
Mailing Address - Fax:623-214-3956
Practice Address - Street 1:12361 W BOLA DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85378-9021
Practice Address - Country:US
Practice Address - Phone:623-214-3335
Practice Address - Fax:623-214-3956
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-14
Last Update Date:2014-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0599213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ842171Medicaid
AZ104693Medicare Oscar/Certification
AZ842171Medicaid