Provider Demographics
NPI:1245760701
Name:INNOVATIVE FOOT AND ANKLE, P.A.
Entity Type:Organization
Organization Name:INNOVATIVE FOOT AND ANKLE, P.A.
Other - Org Name:INNOVATIVE FOOT AND ANKLE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:KAUFMAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:908-276-6624
Mailing Address - Street 1:528 BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:KENILWORTH
Mailing Address - State:NJ
Mailing Address - Zip Code:07033-1657
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:274 MAIN ST
Practice Address - Street 2:
Practice Address - City:LITTLE FERRY
Practice Address - State:NJ
Practice Address - Zip Code:07643-1346
Practice Address - Country:US
Practice Address - Phone:201-440-9444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-18
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8719501Medicaid