Provider Demographics
NPI:1053616086
Name:FOOT AND ANKLE SPECIALIST
Entity type:Organization
Organization Name:FOOT AND ANKLE SPECIALIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GENNADY
Authorized Official - Middle Name:
Authorized Official - Last Name:KOLODENKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:949-651-1202
Mailing Address - Street 1:16405 SAND CANYON AVE STE 270
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-3792
Mailing Address - Country:US
Mailing Address - Phone:949-651-1202
Mailing Address - Fax:
Practice Address - Street 1:16405 SAND CANYON AVE STE 270
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3792
Practice Address - Country:US
Practice Address - Phone:949-651-1202
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-23
Last Update Date:2022-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4880213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty