Healthcare Provider Details

I. General information

NPI: 1093217622
Provider Name (Legal Business Name): ACTIVE PODIATRY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2018
Last Update Date: 09/02/2025
Certification Date: 07/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2035 HAMBURG TPKE STE B
WAYNE NJ
07470-6251
US

IV. Provider business mailing address

2035 HAMBURG TPKE STE B
WAYNE NJ
07470-6251
US

V. Phone/Fax

Practice location:
  • Phone: 201-614-3668
  • Fax: 973-256-4757
Mailing address:
  • Phone: 201-614-3668
  • Fax: 973-256-4757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD0032100
License Number StateNJ

VIII. Authorized Official

Name: HOMAM BADRI
Title or Position: DPM
Credential: DPM
Phone: 201-614-3668