Healthcare Provider Details

I. General information

NPI: 1619502242
Provider Name (Legal Business Name): WESTHAMPTON BEACH PODIATRY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/04/2020
Last Update Date: 03/04/2020
Certification Date: 03/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 C OLD RIVERHEAD ROAD
WESTHAMPTON BEACH NY
11978
US

IV. Provider business mailing address

484 SMITH AVENUE
ISLIP NY
11751
US

V. Phone/Fax

Practice location:
  • Phone: 631-288-1106
  • Fax: 631-979-4002
Mailing address:
  • Phone: 631-833-1528
  • Fax: 631-979-4002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number
License Number State

VIII. Authorized Official

Name: DANIEL JERAN
Title or Position: AUTHORIZED OFFICER
Credential: DPM
Phone: 631-833-1528