Healthcare Provider Details

I. General information

NPI: 1508130873
Provider Name (Legal Business Name): NEW JERSEY FOOT AND ANKLE SPECIALISTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2012
Last Update Date: 02/26/2020
Certification Date: 02/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 ROUTE 23 STE 160
WAYNE NJ
07470-7513
US

IV. Provider business mailing address

1700 ROUTE 23 STE 160
WAYNE NJ
07470-7513
US

V. Phone/Fax

Practice location:
  • Phone: 973-944-0226
  • Fax: 973-695-1035
Mailing address:
  • Phone: 973-944-0226
  • Fax: 973-695-1035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number25MD00301200
License Number StateNJ

VIII. Authorized Official

Name: DR. THEODORE ROBERTO
Title or Position: SOLE MEMBER, MANAGING MEMBER
Credential: D.P.M.
Phone: 973-981-5250