Provider Demographics
NPI:1083610638
Name:JRJ PODIATRY INC
Entity Type:Organization
Organization Name:JRJ PODIATRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEANETTE
Authorized Official - Middle Name:R
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:954-731-0028
Mailing Address - Street 1:4000 N STATE ROAD 7
Mailing Address - Street 2:STE 412
Mailing Address - City:LAUDERDALE LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:33319-4882
Mailing Address - Country:US
Mailing Address - Phone:954-731-0028
Mailing Address - Fax:954-731-0288
Practice Address - Street 1:4000 N STATE ROAD 7
Practice Address - Street 2:STE 412
Practice Address - City:LAUDERDALE LAKES
Practice Address - State:FL
Practice Address - Zip Code:33319-4882
Practice Address - Country:US
Practice Address - Phone:954-731-0028
Practice Address - Fax:954-731-0288
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-27
Last Update Date:2008-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2654213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL390400801Medicaid
FL480027236Medicare ID - Type UnspecifiedRAILROAD MEDICARE
FLK1882Medicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
FL390400801Medicaid