Provider Demographics
NPI:1700076411
Name:PHILIP WROTSLAVSKY, DPM, A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:PHILIP WROTSLAVSKY, DPM, A PROFESSIONAL CORPORATION
Other - Org Name:ADVANCED FOOT AND ANKLE CENTER OF SAN DIEGO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:PHILIP
Authorized Official - Middle Name:
Authorized Official - Last Name:WROTSLAVSKY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:888-451-3770
Mailing Address - Street 1:PO BOX 13613
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92039-3613
Mailing Address - Country:US
Mailing Address - Phone:888-451-3770
Mailing Address - Fax:888-600-8694
Practice Address - Street 1:15525 POMERADO RD
Practice Address - Street 2:SUITE E-6
Practice Address - City:POWAY
Practice Address - State:CA
Practice Address - Zip Code:92064-2435
Practice Address - Country:US
Practice Address - Phone:888-451-3770
Practice Address - Fax:888-600-8694
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-30
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4717261QA1903X, 261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
No261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical