Provider Demographics
NPI:1578211967
Name:JERSEY FAMILY FOOT AND ANKLE LLC
Entity Type:Organization
Organization Name:JERSEY FAMILY FOOT AND ANKLE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PODIATRIC MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:WALTUCH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-510-5487
Mailing Address - Street 1:36 GLENWOOD DR N
Mailing Address - Street 2:
Mailing Address - City:BERGENFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07621-3346
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:36 GLENWOOD DR N
Practice Address - Street 2:
Practice Address - City:BERGENFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07621-3346
Practice Address - Country:US
Practice Address - Phone:718-510-5487
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-14
Last Update Date:2022-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty