Provider Demographics
NPI:1649487992
Name:FOOT AND ANKLE ASSOCIATES OF THE DESERT
Entity type:Organization
Organization Name:FOOT AND ANKLE ASSOCIATES OF THE DESERT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:EBAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:760-863-0070
Mailing Address - Street 1:81709 DR CARREON BLVD
Mailing Address - Street 2:STE D3
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5509
Mailing Address - Country:US
Mailing Address - Phone:760-863-0070
Mailing Address - Fax:760-863-0048
Practice Address - Street 1:81709 DR CARREON BLVD
Practice Address - Street 2:STE D3
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5509
Practice Address - Country:US
Practice Address - Phone:760-863-0070
Practice Address - Fax:760-863-0048
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-17
Last Update Date:2009-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4495213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E44950Medicaid
CAZZZ28495ZMedicare PIN
CA000E44950Medicaid
CA5222190001Medicare NSC