Healthcare Provider Details

I. General information

NPI: 1851518658
Provider Name (Legal Business Name): JB PODIATRIC MEDICINE AND SURGERY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 05/01/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1130 BRIGHTON BEACH AVE APT 1CC
BROOKLYN NY
11235-5515
US

IV. Provider business mailing address

117 CHESTER AVE
STATEN ISLAND NY
10312-5710
US

V. Phone/Fax

Practice location:
  • Phone: 718-648-2707
  • Fax: 347-462-2908
Mailing address:
  • Phone: 917-699-4139
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN006041
License Number StateNY

VIII. Authorized Official

Name: DR. JULIA BONDARENKO
Title or Position: PRESIDENT
Credential: DPM
Phone: 917-699-4139