Provider Demographics
NPI:1437367794
Name:BONNIE VADER, DPM, PC
Entity Type:Organization
Organization Name:BONNIE VADER, DPM, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:VADER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-345-2935
Mailing Address - Street 1:60 RUBY LN
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-3822
Mailing Address - Country:US
Mailing Address - Phone:516-931-0430
Mailing Address - Fax:516-827-1971
Practice Address - Street 1:621 AMBOY ST
Practice Address - Street 2:SUITE 1
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11212-4724
Practice Address - Country:US
Practice Address - Phone:718-345-2935
Practice Address - Fax:718-345-2940
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-18
Last Update Date:2012-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004730213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYKS581OtherOXFORD
NYA100000081OtherGHI MEDICARE
NY1247630Medicaid
NYKS581OtherOXFORD
NY5906380001Medicare NSC
NYP53361Medicare PIN