Healthcare Provider Details

I. General information

NPI: 1770088890
Provider Name (Legal Business Name): LAKEWOOD FOOT AND ANKLE SPECIALIST, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/29/2018
Last Update Date: 03/29/2018
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: 732-905-5160
Mailing address:
  • Phone: 732-367-5151
  • Fax: 732-905-5160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number25MD00332400
License Number State

VIII. Authorized Official

Name: MARILYN SMITH
Title or Position: OFFICE MANAGER
Credential:
Phone: 732-367-5151