Provider Demographics
NPI:1760832851
Name:HARBOR FOOT AND ANKLE PODIATRIC MEDICAL GROUP
Entity type:Organization
Organization Name:HARBOR FOOT AND ANKLE PODIATRIC MEDICAL GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-548-1191
Mailing Address - Street 1:1360 W 6TH ST
Mailing Address - Street 2:SUITE 150W
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-3514
Mailing Address - Country:US
Mailing Address - Phone:310-548-1191
Mailing Address - Fax:
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:SUITE 150W
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-548-1191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty