Provider Demographics
NPI:1992990196
Name:FOOT SPECIALISTS OF TRUMBULL LLC
Entity type:Organization
Organization Name:FOOT SPECIALISTS OF TRUMBULL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:ANTHONY
Authorized Official - Last Name:ETERNO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:203-374-1700
Mailing Address - Street 1:4154 MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3563
Mailing Address - Country:US
Mailing Address - Phone:203-374-1700
Mailing Address - Fax:203-372-1975
Practice Address - Street 1:4154 MADISON AVE
Practice Address - Street 2:
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3563
Practice Address - Country:US
Practice Address - Phone:203-374-1700
Practice Address - Fax:203-372-1975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-11
Last Update Date:2008-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTP00355213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT4610180001Medicare NSC