Healthcare Provider Details

I. General information

NPI: 1396227617
Provider Name (Legal Business Name): MOBILE PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2018
Last Update Date: 11/04/2025
Certification Date: 11/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14845 HILLSIDE AVE FL 1
JAMAICA NY
11435-3308
US

IV. Provider business mailing address

14845 HILLSIDE AVE FL 1
JAMAICA NY
11435-3308
US

V. Phone/Fax

Practice location:
  • Phone: 516-476-1641
  • Fax:
Mailing address:
  • Phone: 516-476-1641
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number005189
License Number StateNY

VIII. Authorized Official

Name: M NAYEEM
Title or Position: DPM
Credential:
Phone: 516-476-1641