Provider Demographics
NPI:1366758104
Name:ELITE PODIATRY, PLLC
Entity type:Organization
Organization Name:ELITE PODIATRY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:LOO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:602-321-0292
Mailing Address - Street 1:13838 S 46TH PL
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-7800
Mailing Address - Country:US
Mailing Address - Phone:480-213-3011
Mailing Address - Fax:480-816-4483
Practice Address - Street 1:13838 S 46TH PL
Practice Address - Street 2:SUITE 210
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-7800
Practice Address - Country:US
Practice Address - Phone:480-213-3011
Practice Address - Fax:480-816-4483
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2016-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0502213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty