1972990372 NPI number — FOOT AND ANKLE WELLNESS PODIATRY PC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972990372 NPI number — FOOT AND ANKLE WELLNESS PODIATRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOOT AND ANKLE WELLNESS 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:
1972990372
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/23/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
729 MONROE ST
Provider Second Line Business Mailing Address:
APT 3R
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11221-5525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
713-898-5283
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
121 DEKALB AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11201-5425
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
713-898-5283
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/23/2015

Additional Information

Authorized Official

Authorized Official Last Name:
EL-KHASHAB
Authorized Official First Name:
AMR
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
713-898-5283

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  006607 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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