Provider Demographics
NPI:1902907835
Name:ADDIEGO, JOSEPH ANTHONY (DPM)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:ANTHONY
Last Name:ADDIEGO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3174
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91221-0174
Mailing Address - Country:US
Mailing Address - Phone:818-242-3668
Mailing Address - Fax:818-242-2425
Practice Address - Street 1:1510 S CENTRAL AVE
Practice Address - Street 2:SUITE 120
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91204-2577
Practice Address - Country:US
Practice Address - Phone:818-242-3668
Practice Address - Fax:818-242-3668
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4289213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E42893Medicaid
CAE4289Medicare ID - Type Unspecified
CA4871100001Medicare NSC
U81456Medicare UPIN