Provider Demographics
NPI:1700015849
Name:CORY HAIMON DPM PA
Entity Type:Organization
Organization Name:CORY HAIMON DPM PA
Other - Org Name:GOLD COAST PODIATRY GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:IRA
Authorized Official - Middle Name:J
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:561-993-3668
Mailing Address - Street 1:7431 W ATLANTIC AVE STE 33
Mailing Address - Street 2:
Mailing Address - City:DELRAY BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33446-3505
Mailing Address - Country:US
Mailing Address - Phone:561-496-6900
Mailing Address - Fax:561-496-5348
Practice Address - Street 1:941 SE 1ST ST
Practice Address - Street 2:SUITE B
Practice Address - City:BELLE GLADE
Practice Address - State:FL
Practice Address - Zip Code:33430-4353
Practice Address - Country:US
Practice Address - Phone:561-993-3668
Practice Address - Fax:561-993-3668
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CORY HAIMON DPM PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-07-10
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO0001689213E00000X
FLPO0001592213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390417200Medicaid
FL72837AMedicare PIN
FL390417200Medicaid