Provider Demographics
NPI:1720445281
Name:PREMIER PODIATRY
Entity Type:Organization
Organization Name:PREMIER PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:P
Authorized Official - Last Name:LICANDRO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:563-340-4387
Mailing Address - Street 1:PO BOX 2671
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52809-2671
Mailing Address - Country:US
Mailing Address - Phone:832-425-7457
Mailing Address - Fax:563-285-5447
Practice Address - Street 1:405 WOODLAWN RD
Practice Address - Street 2:
Practice Address - City:LONG GROVE
Practice Address - State:IA
Practice Address - Zip Code:52756-8745
Practice Address - Country:US
Practice Address - Phone:832-425-7457
Practice Address - Fax:563-424-7234
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0705213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty