Provider Demographics
NPI:1649884610
Name:SOUTH BAY FOOT & ANKLE SPECIALISTS, INC.
Entity type:Organization
Organization Name:SOUTH BAY FOOT & ANKLE SPECIALISTS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:ANGUS
Authorized Official - Last Name:CHISHOLM
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:619-427-3481
Mailing Address - Street 1:345 F ST STE 100
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91910-2632
Mailing Address - Country:US
Mailing Address - Phone:619-427-3481
Mailing Address - Fax:
Practice Address - Street 1:5565 GROSSMONT CENTER DR STE 510
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3024
Practice Address - Country:US
Practice Address - Phone:941-776-4822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
BZS56322222OtherLIABILITY INSURANCE