Provider Demographics
NPI:1750360699
Name:LODI PODIATRY GROUP
Entity type:Organization
Organization Name:LODI PODIATRY GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KERRY
Authorized Official - Middle Name:LYN
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:209-334-0429
Mailing Address - Street 1:1300 W LODI AVE
Mailing Address - Street 2:STE W
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3038
Mailing Address - Country:US
Mailing Address - Phone:209-334-6664
Mailing Address - Fax:209-334-2379
Practice Address - Street 1:1300 W LODI AVE
Practice Address - Street 2:STE W
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3038
Practice Address - Country:US
Practice Address - Phone:209-334-6664
Practice Address - Fax:209-334-2379
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-10
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3241213E00000X, 213ER0200X, 213ES0103X
CAE3467213ER0200X, 213ES0103X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213ER0200XPodiatric Medicine & Surgery Service ProvidersPodiatristRadiologyGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E32410Medicaid
CA000E34670Medicaid
CA000E34670Medicare ID - Type UnspecifiedSTROH'S M/CARE #
CA000E32410Medicare ID - Type UnspecifiedSHOCK'S M/CARE #
CA000E32410Medicaid
CA0841340001Medicare NSC
CAT11594Medicare UPIN