Healthcare Provider Details

I. General information

NPI: 1013640648
Provider Name (Legal Business Name): JOHN EGDORF
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOHN EGDORF DPM

II. Dates (important events)

Enumeration Date: 07/01/2022
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date: 03/20/2023
Reactivation Date: 06/22/2023

III. Provider practice location address

160 RIDGE RD
LYNDHURST NJ
07071-1275
US

IV. Provider business mailing address

160 RIDGE RD
LYNDHURST NJ
07071-1275
US

V. Phone/Fax

Practice location:
  • Phone: 201-939-9098
  • Fax:
Mailing address:
  • Phone: 201-939-9098
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00392900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: