Healthcare Provider Details

I. General information

NPI: 1982769477
Provider Name (Legal Business Name): ALUKO OSAFO JERVIS D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/26/2006
Last Update Date: 02/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

295 MYRTLE AVE
STATEN ISLAND NY
10310-2332
US

IV. Provider business mailing address

295 MYRTLE AVE
STATEN ISLAND NY
10310-2332
US

V. Phone/Fax

Practice location:
  • Phone: 718-720-6866
  • Fax: 718-720-6931
Mailing address:
  • Phone: 718-273-2984
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN006185-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: