=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457390361
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KENNETH FRANCIS SEBASTIAN DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/06/2006
-----------------------------------------------------
Last Update Date | 10/22/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 217 LAUREL RD E
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08084-1301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-783-6361
-----------------------------------------------------
Fax | 856-783-0168
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 217 LAUREL RD E
-----------------------------------------------------
City | STRATFORD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08084-1301
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-783-6361
-----------------------------------------------------
Fax | 856-783-0168
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number | 25MD00108800
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------