Healthcare Provider Details

I. General information

NPI: 1568950087
Provider Name (Legal Business Name): YAKOV GROYSMAN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2018
Last Update Date: 04/06/2022
Certification Date: 04/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20 PROSPECT AVE STE 803H
HACKENSACK NJ
07601-1997
US

IV. Provider business mailing address

25 WHITE OAK LN
MATAWAN NJ
07747-1968
US

V. Phone/Fax

Practice location:
  • Phone: 201-488-3668
  • Fax:
Mailing address:
  • Phone: 718-427-0183
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00364500
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: