Provider Demographics
NPI:1164442182
Name:1 WISE PODIATRY CARE P.C.
Entity Type:Organization
Organization Name:1 WISE PODIATRY CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YELENA
Authorized Official - Middle Name:
Authorized Official - Last Name:VORONOVA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-554-3862
Mailing Address - Street 1:3079 BRIGHTON 13TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5607
Mailing Address - Country:US
Mailing Address - Phone:718-554-3862
Mailing Address - Fax:718-554-0979
Practice Address - Street 1:3079 BRIGHTON 13TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5607
Practice Address - Country:US
Practice Address - Phone:718-554-3862
Practice Address - Fax:718-554-0979
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-20
Last Update Date:2020-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005994213ES0131X, 213ES0131X
261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatricGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03015047Medicaid
NYPDWF71Medicare PIN
NY03015047Medicaid
NYU99474Medicare UPIN