Provider Demographics
NPI:1700060902
Name:EVANSTON FAMILY FOOT CARE
Entity Type:Organization
Organization Name:EVANSTON FAMILY FOOT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:CANNON
Authorized Official - Last Name:LEVITRE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:307-789-8997
Mailing Address - Street 1:PO BOX 238
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:WY
Mailing Address - Zip Code:82931-0238
Mailing Address - Country:US
Mailing Address - Phone:307-789-8997
Mailing Address - Fax:307-789-2624
Practice Address - Street 1:1565 HIGHWAY 150 SOUTH
Practice Address - Street 2:SUITE C
Practice Address - City:EVANSTON
Practice Address - State:WY
Practice Address - Zip Code:82930-5348
Practice Address - Country:US
Practice Address - Phone:307-789-8997
Practice Address - Fax:307-789-2624
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-24
Last Update Date:2008-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY127213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WYDD8254OtherRAILROAD MEDICARE
WY1217844 00Medicaid
WY1217844 00Medicaid
WY5693300001Medicare NSC
WYW20446Medicare PIN