Provider Demographics
NPI:1194944728
Name:PODIATRIC PHYSICIANS OF ARIZONA, INC.
Entity type:Organization
Organization Name:PODIATRIC PHYSICIANS OF ARIZONA, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:ASHLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:617-562-7070
Mailing Address - Street 1:PO BOX 847818
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-7818
Mailing Address - Country:US
Mailing Address - Phone:480-834-8804
Mailing Address - Fax:480-464-8287
Practice Address - Street 1:1620 S STAPLEY DR
Practice Address - Street 2:132
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6634
Practice Address - Country:US
Practice Address - Phone:480-834-8804
Practice Address - Fax:480-464-8287
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-24
Last Update Date:2020-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZCD4380OtherPALMETTO GBA, RAILROAD MEDICARE
AZ500144Medicaid
AZ500144Medicaid
AZZWCHHTMedicare PIN