Healthcare Provider Details

I. General information

NPI: 1255757241
Provider Name (Legal Business Name): LADY PAULA DEJESUS, DPM, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 03/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23-18 BROADWAY
ASTORIA NY
11106
US

IV. Provider business mailing address

23-18 BROADWAY
ASTORIA NY
11106
US

V. Phone/Fax

Practice location:
  • Phone: 347-820-2531
  • Fax:
Mailing address:
  • Phone: 347-820-2531
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number006439
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number006439
License Number StateNY

VIII. Authorized Official

Name: LADY PAULA DEJESUS
Title or Position: OWNER
Credential: DPM
Phone: 347-820-2531