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General NPI Number Information
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NPI Number | 1013953926
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Entity Type | Organization
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Legal Business Name | PORT WASHINGTON PODIATRY INC
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Dates
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Enumeration Date | 06/20/2006
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Last Update Date | 04/20/2008
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Provider Practice Location Address
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Address Line | 1317 W GRAND AVENUE PORT WASHINGTON PODIATRY
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City | PORT WASHINGTON
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State | WI
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Zip | 53074
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Country | US
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Telephone | 262-284-8800
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Fax | 262-284-8861
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Provider Business Mailing Address
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Address Line | 2132 WILLOW POND WAY
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City | GRAFTON
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State | WI
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Zip | 53024-9102
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Country | US
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Telephone | 262-284-8800
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Fax | 262-284-8861
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Authorized Official
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Title or Position | PRESIDENT
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Name | JEFFREY JOSEPH BONGIORNO
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Credential | DPM
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Telephone | 262-284-8800
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | 798025
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License Number State | WI
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