Provider Demographics
NPI:1508116823
Name:BORTNIKER, KEITH (DPM)
Entity Type:Individual
Prefix:DR
First Name:KEITH
Middle Name:
Last Name:BORTNIKER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:59 S CONSTITUTION DR
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-1622
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2 CROSFIELD AVE STE 302
Practice Address - Street 2:
Practice Address - City:WEST NYACK
Practice Address - State:NY
Practice Address - Zip Code:10994-2218
Practice Address - Country:US
Practice Address - Phone:845-358-2844
Practice Address - Fax:845-358-0528
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-13
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NYNY-N006715-1213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program