Provider Demographics
NPI:1578673638
Name:SAN MATEO PODIATRY GROUP, A PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:SAN MATEO PODIATRY GROUP, A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BILL
Authorized Official - Middle Name:J
Authorized Official - Last Name:METAXAS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:415-433-3668
Mailing Address - Street 1:1750 EL CAMINO REAL STE 106
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3210
Mailing Address - Country:US
Mailing Address - Phone:650-342-2420
Mailing Address - Fax:650-342-2391
Practice Address - Street 1:1750 EL CAMINO REAL STE 106
Practice Address - Street 2:
Practice Address - City:BURLINGAME
Practice Address - State:CA
Practice Address - Zip Code:94010-3210
Practice Address - Country:US
Practice Address - Phone:650-342-2420
Practice Address - Fax:650-342-2391
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-30
Last Update Date:2020-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0821580001Medicare NSC