Healthcare Provider Details

I. General information

NPI: 1396456836
Provider Name (Legal Business Name): JOSE GRULLON DPM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2022
Last Update Date: 12/06/2022
Certification Date: 12/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 KENNEDY BLVD
NORTH BERGEN NJ
07047-3420
US

IV. Provider business mailing address

6301 KENNEDY BLVD
NORTH BERGEN NJ
07047-3420
US

V. Phone/Fax

Practice location:
  • Phone: 201-662-8700
  • Fax: 201-453-8075
Mailing address:
  • Phone: 201-662-8700
  • Fax: 201-453-8075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: MEHTAB ABBASI
Title or Position: OFFICE MANAGER
Credential:
Phone: 917-336-8422