Healthcare Provider Details

I. General information

NPI: 1962021857
Provider Name (Legal Business Name): AKHILA ANU ISSAC DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2020
Last Update Date: 11/18/2024
Certification Date: 11/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MORRIS AVE STE 203
SPRINGFIELD NJ
07081-1020
US

IV. Provider business mailing address

500 MORRIS AVE STE 203
SPRINGFIELD NJ
07081-1020
US

V. Phone/Fax

Practice location:
  • Phone: 973-376-8210
  • Fax:
Mailing address:
  • Phone: 973-376-8210
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number135.001100
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00383600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: