Healthcare Provider Details

I. General information

NPI: 1639678246
Provider Name (Legal Business Name): LAKEWOOD FOOT AND ANKLE SPECIALISTS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2018
Last Update Date: 03/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MADISON AVE
LAKEWOOD NJ
08701-1253
US

IV. Provider business mailing address

1700 MADISON AVE
LAKEWOOD NJ
08701-1253
US

V. Phone/Fax

Practice location:
  • Phone: 732-367-5151
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00332400
License Number StateNJ

VIII. Authorized Official

Name: GLENN MICHAEL AUFSEESER
Title or Position: DPM
Credential:
Phone: 732-367-5151