Healthcare Provider Details

I. General information

NPI: 1609808443
Provider Name (Legal Business Name): JAY S LEBOW DPM PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1626 E FORT AVE
BALTIMORE MD
21230-5245
US

IV. Provider business mailing address

1626 E FORT AVE
BALTIMORE MD
21230-5245
US

V. Phone/Fax

Practice location:
  • Phone: 410-332-1414
  • Fax: 410-332-1423
Mailing address:
  • Phone: 410-332-1414
  • Fax: 410-332-1423

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DR. JAY S. LEBOW
Title or Position: PRESIDENT
Credential: DPM
Phone: 410-332-1414