=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649418567
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEYSTONE PODIATRY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2009
-----------------------------------------------------
Last Update Date | 01/30/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3040 E TREMONT AVE RM 101
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10461-5733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-931-9058
-----------------------------------------------------
Fax | 718-918-0004
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3040 E TREMONT AVE RM 101
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10461-5733
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-931-9058
-----------------------------------------------------
Fax | 718-918-0004
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SECRETARY
-----------------------------------------------------
Name | MS. LISSETTE CARTAGENA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 718-931-9058
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213EP1101X
-----------------------------------------------------
Taxonomy Name | Primary Podiatric Medicine Podiatrist
-----------------------------------------------------
License Number | 003843-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------