Provider Demographics
NPI:1285080978
Name:PACIFIC COAST PODIATRY PC
Entity type:Organization
Organization Name:PACIFIC COAST PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CLAYTON
Authorized Official - Middle Name:GARY
Authorized Official - Last Name:JOHNSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:909-886-3668
Mailing Address - Street 1:1762 N WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-5130
Mailing Address - Country:US
Mailing Address - Phone:909-886-3668
Mailing Address - Fax:909-886-5542
Practice Address - Street 1:1762 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-5130
Practice Address - Country:US
Practice Address - Phone:909-886-3668
Practice Address - Fax:909-886-5542
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-11
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4834305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
1285080978OtherNPI