Healthcare Provider Details

I. General information

NPI: 1164442182
Provider Name (Legal Business Name): 1 WISE PODIATRY CARE P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 02/06/2020
Certification Date: 02/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3079 BRIGHTON 13TH ST
BROOKLYN NY
11235-5607
US

IV. Provider business mailing address

3079 BRIGHTON 13TH ST
BROOKLYN NY
11235-5607
US

V. Phone/Fax

Practice location:
  • Phone: 718-554-3862
  • Fax: 718-554-0979
Mailing address:
  • Phone: 718-554-3862
  • Fax: 718-554-0979

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN005994
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: YELENA VORONOVA
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 718-554-3862