Healthcare Provider Details

I. General information

NPI: 1114455920
Provider Name (Legal Business Name): EVOLVE FOOT AND ANKLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2017
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1529 ROUTE 206 STE L
TABERNACLE NJ
08088-8801
US

IV. Provider business mailing address

PO BOX 468
MARLTON NJ
08053-0468
US

V. Phone/Fax

Practice location:
  • Phone: 856-422-2323
  • Fax: 856-872-4544
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number25MD00336100
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: URWAH HAQ
Title or Position: PHYSICIAN
Credential: DPM
Phone: 856-422-2323