Provider Demographics
NPI:1093217622
Name:ACTIVE PODIATRY LLC
Entity Type:Organization
Organization Name:ACTIVE PODIATRY LLC
Other - Org Name:ACTIVE PODIATRY LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DPM
Authorized Official - Prefix:
Authorized Official - First Name:HOMAM
Authorized Official - Middle Name:
Authorized Official - Last Name:BADRI
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-614-3668
Mailing Address - Street 1:PO BOX 4293
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07474-4293
Mailing Address - Country:US
Mailing Address - Phone:201-614-3668
Mailing Address - Fax:973-256-4757
Practice Address - Street 1:7823 BERGENLINE AVE FL 2
Practice Address - Street 2:
Practice Address - City:NORTH BERGEN
Practice Address - State:NJ
Practice Address - Zip Code:07047-4942
Practice Address - Country:US
Practice Address - Phone:201-614-3668
Practice Address - Fax:973-256-4757
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-02-28
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD0032100213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0429732Medicaid