Healthcare Provider Details

I. General information

NPI: 1700029048
Provider Name (Legal Business Name): HILLSBOROUGH PODIATRY GROUP, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 05/29/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 ROUTE 206 SUITE 107
HILLSBOROUGH NJ
08844-1536
US

IV. Provider business mailing address

719 ROUTE 206 SUITE 107
HILLSBOROUGH NJ
08844-1536
US

V. Phone/Fax

Practice location:
  • Phone: 908-431-5901
  • Fax: 908-431-5906
Mailing address:
  • Phone: 908-431-5901
  • Fax: 908-431-5906

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number25MD00253800
License Number StateNJ

VIII. Authorized Official

Name: DR. MARC LEONARD MIZRACHY
Title or Position: OWNER
Credential: DPM
Phone: 908-431-5901