Provider Demographics
NPI:1053774596
Name:SOLE PODIATRY CENTER PA
Entity type:Organization
Organization Name:SOLE PODIATRY CENTER PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:KIBRIA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:239-353-1555
Mailing Address - Street 1:5475 GOLDEN GATE PKWY
Mailing Address - Street 2:STE 4
Mailing Address - City:NAPLES
Mailing Address - State:FL
Mailing Address - Zip Code:34116-7529
Mailing Address - Country:US
Mailing Address - Phone:239-353-1555
Mailing Address - Fax:239-353-7001
Practice Address - Street 1:5475 GOLDEN GATE PKWY
Practice Address - Street 2:STE 4
Practice Address - City:NAPLES
Practice Address - State:FL
Practice Address - Zip Code:34116-7529
Practice Address - Country:US
Practice Address - Phone:239-353-1555
Practice Address - Fax:239-353-7001
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SOLE PODIATRY CENTER PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-04-01
Last Update Date:2016-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLP03769213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty