Provider Demographics
NPI:1801065040
Name:KITSAP PODIATRY PLLC
Entity type:Organization
Organization Name:KITSAP PODIATRY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:W
Authorized Official - Last Name:AUFDERHEIDE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:360-698-2505
Mailing Address - Street 1:10049 KITSAP MALL BLVD NW
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-8903
Mailing Address - Country:US
Mailing Address - Phone:360-698-2505
Mailing Address - Fax:360-698-2514
Practice Address - Street 1:10049 KITSAP MALL BLVD NW
Practice Address - Street 2:SUITE 109
Practice Address - City:SILVERDALE
Practice Address - State:WA
Practice Address - Zip Code:98383-8903
Practice Address - Country:US
Practice Address - Phone:360-698-2505
Practice Address - Fax:360-698-2514
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-21
Last Update Date:2011-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7125180Medicaid
WA1134326283OtherNPI - RYAN DOWNEY, DPM
WADN6457OtherRAILROAD MEDICARE GROUP PTAN
WAG8870860OtherPTAN
WA1730260241OtherINDIVIDUAL NPI - PAUL W AUFDERHEIDE
WA1801065040OtherGROUP NPI - KITSAP PODIATRY
WAP00630592OtherRAILROAD MEDICARE GROUP MEMBER PTAN
WA1730260241OtherINDIVIDUAL NPI - PAUL W AUFDERHEIDE
WA7125180Medicaid