Provider Demographics
NPI:1124194410
Name:GROSSMAN, WENDY LYNN (DPM)
Entity Type:Individual
Prefix:DR
First Name:WENDY
Middle Name:LYNN
Last Name:GROSSMAN
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-2869
Mailing Address - Country:US
Mailing Address - Phone:973-566-0811
Mailing Address - Fax:973-566-0833
Practice Address - Street 1:905 BROAD ST
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-2869
Practice Address - Country:US
Practice Address - Phone:973-566-0811
Practice Address - Fax:973-566-0833
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-28
Last Update Date:2012-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00230300213ES0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6641601Medicaid
NJ6641601Medicaid
NJGR788674Medicare ID - Type Unspecified