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General NPI Number Information
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NPI Number | 1093217622
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Entity Type | Organization
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Legal Business Name | ACTIVE PODIATRY LLC
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Dates
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Enumeration Date | 02/28/2018
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Last Update Date | 09/02/2025
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Provider Practice Location Address
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Address Line | 2035 HAMBURG TPKE STE B
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City | WAYNE
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State | NJ
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Zip | 07470-6251
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Country | US
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Telephone | 201-614-3668
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Fax | 973-256-4757
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Provider Business Mailing Address
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Address Line | 2035 HAMBURG TPKE STE B
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City | WAYNE
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State | NJ
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Zip | 07470-6251
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Country | US
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Telephone | 201-614-3668
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Fax | 973-256-4757
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Authorized Official
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Title or Position | DPM
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Name | HOMAM BADRI
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Credential | DPM
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Telephone | 201-614-3668
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 25MD0032100
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License Number State | NJ
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