Healthcare Provider Details

I. General information

NPI: 1710934278
Provider Name (Legal Business Name): JOHN J BERONIO DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 08/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 NORTH FRANKLIN TPKE
WALDWICK NJ
07463
US

IV. Provider business mailing address

171 NORTH FRANKLIN TPKE
WALDWICK NJ
07463
US

V. Phone/Fax

Practice location:
  • Phone: 201-447-8190
  • Fax: 201-447-4298
Mailing address:
  • Phone: 201-447-8190
  • Fax: 201-447-4298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberMD2304
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: