Healthcare Provider Details

I. General information

NPI: 1427246354
Provider Name (Legal Business Name): COMPREHENSIVE FAMILY FOOT CARE, PA.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2007
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 FRANKLIN TPKE STE 202
MAHWAH NJ
07430-3516
US

IV. Provider business mailing address

400 FRANKLIN TPKE STE 202
MAHWAH NJ
07430-3516
US

V. Phone/Fax

Practice location:
  • Phone: 201-818-9114
  • Fax: 201-934-8223
Mailing address:
  • Phone: 201-818-9114
  • Fax: 201-934-8223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number25MD00180700
License Number StateNJ

VIII. Authorized Official

Name: LISSA GILLESPIE
Title or Position: OFFICE MANAGER
Credential:
Phone: 201-818-9114