Provider Demographics
NPI:1194864041
Name:CARVAJAL, MARTHA (DPM)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:
Last Name:CARVAJAL
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 1:221 60TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-2805
Mailing Address - Country:US
Mailing Address - Phone:201-758-9300
Mailing Address - Fax:
Practice Address - Street 1:221 60TH ST
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-2805
Practice Address - Country:US
Practice Address - Phone:201-758-9300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB00260600213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8340307Medicaid
NJU82583Medicare UPIN
NJ043494Medicare ID - Type Unspecified