Basic Information
| Provider Information | |||||||||
| NPI: | 1285080978 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PACIFIC COAST PODIATRY PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1762 N WATERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924045130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098863668 | ||||||||
| FaxNumber: | 9098865542 | ||||||||
| Practice Location | |||||||||
| Address1: | 1762 N WATERMAN AVE | ||||||||
| Address2: | |||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924045130 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098863668 | ||||||||
| FaxNumber: | 9098865542 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2016 | ||||||||
| LastUpdateDate: | 06/20/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSEN | ||||||||
| AuthorizedOfficialFirstName: | CLAYTON | ||||||||
| AuthorizedOfficialMiddleName: | GARY | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 9098863668 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.P.M | ||||||||
| NPICertificationDate: | 06/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 305R00000X | E4834 | CA | Y | Managed Care Organizations | Preferred Provider Organization |
ID Information
| ID | Type | State | Issuer | Description | 1285080978 | 01 | NPI | OTHER |