Provider Demographics
NPI:1699802090
Name:FAMILY FOOTCARE, PC
Entity type:Organization
Organization Name:FAMILY FOOTCARE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:M
Authorized Official - Last Name:DEJESUS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-723-7884
Mailing Address - Street 1:1183 NEW HAVEN RD
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-5033
Mailing Address - Country:US
Mailing Address - Phone:203-723-7884
Mailing Address - Fax:203-723-2946
Practice Address - Street 1:1183 NEW HAVEN RD
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-5033
Practice Address - Country:US
Practice Address - Phone:203-723-7884
Practice Address - Fax:203-723-2946
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-27
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
213EP1101X, 332B00000X, 213EP1101X
CT00454213ES0103X
CT00461213ES0103X
CT000454332B00000X, 332BC3200X
CT000461332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Single Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized EquipmentGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004225703Medicaid
CT004094554Medicaid
CTC00823Medicare PIN
CT004094554Medicaid