MEDICARE: 1 WISE PODIATRY CARE P.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QP1100X	Podiatric Clinic/Center
2	213ES0131X	Foot Surgery Podiatrist	N005994	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164442182
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	1 WISE PODIATRY CARE P.C.

Provider Business Mailing Address
First Line	:	3079 BRIGHTON 13TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5607
Country	:	US
Telephone Number	:	718-554-3862
Fax Number	:	718-554-0979

Provider Business Practice Location Address
First Line	:	3079 BRIGHTON 13TH ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11235-5607
Country	:	US
Telephone Number	:	718-554-3862
Fax Number	:	718-554-0979

Authorized Official
Title or Position	:	PRESIDENT
Name	:	YELENA VORONOVA
Credential	:	D.P.M.
Telephone Number	:	718-554-3862

Provider Enumeration Date	:	07/20/2006
Last Update Date	:	02/06/2020

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