Provider Demographics
NPI:1245426337
Name:BOONTON PODIATRY
Entity Type:Organization
Organization Name:BOONTON PODIATRY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RONIGER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:973-402-1973
Mailing Address - Street 1:223 W MAIN ST
Mailing Address - Street 2:SUITE 1B
Mailing Address - City:BOONTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07005-1166
Mailing Address - Country:US
Mailing Address - Phone:973-402-1973
Mailing Address - Fax:973-402-1969
Practice Address - Street 1:223 W MAIN ST
Practice Address - Street 2:SUITE 1B
Practice Address - City:BOONTON
Practice Address - State:NJ
Practice Address - Zip Code:07005-1166
Practice Address - Country:US
Practice Address - Phone:973-402-1973
Practice Address - Fax:973-402-1969
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-21
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD01978213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3444805Medicaid