Provider Demographics
NPI:1124175740
Name:FAR WEST PODIATRIC MEDICAL GROUP
Entity type:Organization
Organization Name:FAR WEST PODIATRIC MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:L
Authorized Official - Last Name:WRUBEL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-675-0900
Mailing Address - Street 1:13624 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 206
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90250-5818
Mailing Address - Country:US
Mailing Address - Phone:310-675-0900
Mailing Address - Fax:310-675-0904
Practice Address - Street 1:13624 HAWTHORNE BLVD STE 206
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90250-5818
Practice Address - Country:US
Practice Address - Phone:310-675-0900
Practice Address - Fax:310-675-0904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3328213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGRE001780Medicaid
CAGRE001780Medicaid
5708490001Medicare NSC