MEDICARE: DR. SPERO EVAN DEMOLEAS D.P.M.

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	213ES0103X	Foot & Ankle Surgery Podiatrist	MD01964	NJ
2	213ES0103X	Foot & Ankle Surgery Podiatrist	N004380	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PG6421	OTHER	NY	BC/BS NY

General Provider Information

NPI Number	:	1295776755
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SPERO EVAN DEMOLEAS D.P.M.

Provider Business Mailing Address
First Line	:	215 OLD TAPPAN RD
Second Line	:
City	:	OLD TAPPAN
State	:	NJ
Zip	:	07675-7000
Country	:	US
Telephone Number	:	201-930-9090
Fax Number	:	201-930-1823

Provider Business Practice Location Address
First Line	:	215 OLD TAPPAN RD
Second Line	:
City	:	OLD TAPPAN
State	:	NJ
Zip	:	07675-7000
Country	:	US
Telephone Number	:	201-930-9090
Fax Number	:	201-930-1823

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/08/2006
Last Update Date	:	12/02/2011

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Directions to “ DR. SPERO EVAN DEMOLEAS D.P.M.” Practice Location

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