1053692251 NPI number — CHELSEA VILLAGE PODIATRY PC

Table of content: (NPI 1053692251)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053692251 NPI number — CHELSEA VILLAGE PODIATRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHELSEA VILLAGE PODIATRY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1053692251
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
420 74TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11209-2602
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-836-1017
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
314 W 14TH ST
Provider Second Line Business Practice Location Address:
6TH FLOOR
Provider Business Practice Location Address City Name:
NEW YORK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10014-5002
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
212-366-1548
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/31/2011

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
SHARMA
Authorized Official First Name:
SIDDHARTHA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
718-836-1017

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  25MD00305100 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 213ES0103X , with the licence number: N006276 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)