Healthcare Provider Details

I. General information

NPI: 1972540854
Provider Name (Legal Business Name): ASSOC. OF MAPLE PODIATRY,PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 07/01/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 W MAPLE AVE
MERCHANTVILLE NJ
08109-1822
US

IV. Provider business mailing address

702 W MAPLE AVE
MERCHANTVILLE NJ
08109-1822
US

V. Phone/Fax

Practice location:
  • Phone: 856-665-1180
  • Fax: 856-665-5537
Mailing address:
  • Phone: 856-665-1180
  • Fax: 856-665-5537

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberMD00151900
License Number StateNJ

VIII. Authorized Official

Name: DR. JOHN A WALLACE
Title or Position: OWNER
Credential: DPM
Phone: 856-665-1180