Healthcare Provider Details

I. General information

NPI: 1912596271
Provider Name (Legal Business Name): 5 BORO PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/12/2021
Last Update Date: 01/12/2021
Certification Date: 01/12/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 TARGEE ST
STATEN ISLAND NY
10304-3501
US

IV. Provider business mailing address

1578 WILLIAMSBRIDGE RD APT 3A
BRONX NY
10461-6268
US

V. Phone/Fax

Practice location:
  • Phone: 646-837-5448
  • Fax: 718-775-3150
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: SADIA SHAH
Title or Position: OWNER
Credential:
Phone: 917-613-1629