Healthcare Provider Details

I. General information

NPI: 1649418567
Provider Name (Legal Business Name): KEYSTONE PODIATRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2009
Last Update Date: 01/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3040 E TREMONT AVE RM 101
BRONX NY
10461-5733
US

IV. Provider business mailing address

3040 E TREMONT AVE RM 101
BRONX NY
10461-5733
US

V. Phone/Fax

Practice location:
  • Phone: 718-931-9058
  • Fax: 718-918-0004
Mailing address:
  • Phone: 718-931-9058
  • Fax: 718-918-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number003843-1
License Number StateNY

VIII. Authorized Official

Name: MS. LISSETTE CARTAGENA
Title or Position: SECRETARY
Credential:
Phone: 718-931-9058