=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477583987
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | STEVEN JAY MARDER DPM
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/03/2006
-----------------------------------------------------
Last Update Date | 10/11/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1049 BROADWAY
-----------------------------------------------------
City | WEST LONG BRANCH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-870-9700
-----------------------------------------------------
Fax | 732-571-7873
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1049 BROADWAY
-----------------------------------------------------
City | WEST LONG BRANCH
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07764
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 732-870-9700
-----------------------------------------------------
Fax | 732-571-7873
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | MD01368
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------