Provider Demographics
NPI:1063518132
Name:ADVANCED FOOT CLINIC, PC
Entity type:Organization
Organization Name:ADVANCED FOOT CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AZADEH
Authorized Official - Middle Name:
Authorized Official - Last Name:ARABSHAHI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-391-0688
Mailing Address - Street 1:PO BOX 1550
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-1550
Mailing Address - Country:US
Mailing Address - Phone:503-612-4040
Mailing Address - Fax:503-625-8638
Practice Address - Street 1:6464 SW BORLAND RD STE B3
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-8855
Practice Address - Country:US
Practice Address - Phone:503-612-4040
Practice Address - Fax:503-625-8638
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-16
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00296213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR116947OtherMEDICARE
OR5738490002OtherMEDICARE DME
OR480034478OtherRAILROAD MEDICARE
OR158911Medicaid
OR480034478OtherPALMETTO GBA
OR480034478OtherRAILROAD MEDICARE
OR158911Medicaid
OR5738490002Medicare NSC