Healthcare Provider Details

I. General information

NPI: 1356734339
Provider Name (Legal Business Name): MAIN STREET FOOT AND ANKLE CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2015
Last Update Date: 03/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

618 MAIN ST
TOMS RIVER NJ
08753-7424
US

IV. Provider business mailing address

618 MAIN ST
TOMS RIVER NJ
08753-7424
US

V. Phone/Fax

Practice location:
  • Phone: 732-349-0114
  • Fax: 732-349-0228
Mailing address:
  • Phone: 732-349-0114
  • Fax: 732-349-0228

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number25MD00193900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00193900
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number25MD00193900
License Number StateNJ

VIII. Authorized Official

Name: MARK A MAJESKI
Title or Position: DPM/OWNER
Credential: DPM
Phone: 732-349-0114