Provider Demographics
NPI:1124380688
Name:LOS GATOS PODIATRY GROUP, INC.
Entity type:Organization
Organization Name:LOS GATOS PODIATRY GROUP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:AZAR
Authorized Official - Middle Name:
Authorized Official - Last Name:DASTGAH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:408-358-2250
Mailing Address - Street 1:14651 S BASCOM AVE
Mailing Address - Street 2:SUITE 215
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-2014
Mailing Address - Country:US
Mailing Address - Phone:408-358-2250
Mailing Address - Fax:408-358-2258
Practice Address - Street 1:14651 S BASCOM AVE
Practice Address - Street 2:SUITE 215
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2014
Practice Address - Country:US
Practice Address - Phone:408-358-2250
Practice Address - Fax:408-358-2258
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-06-11
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4988213ES0103X
CAE4916213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6722560001Medicare NSC