Provider Demographics
NPI:1609808443
Name:JAY S LEBOW DPM PA
Entity Type:Organization
Organization Name:JAY S LEBOW DPM PA
Other - Org Name:LEBOW PODIATRY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:S
Authorized Official - Last Name:LEBOW
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:410-332-1414
Mailing Address - Street 1:1626 E FORT AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-5245
Mailing Address - Country:US
Mailing Address - Phone:410-332-1414
Mailing Address - Fax:410-332-1423
Practice Address - Street 1:1626 E FORT AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21230-5245
Practice Address - Country:US
Practice Address - Phone:410-332-1414
Practice Address - Fax:410-332-1423
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-06
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD480002770OtherMEDICARE RAILROAD
MD548128700Medicaid
MD0811140001Medicare NSC
MDK267Medicare ID - Type Unspecified
MD548128700Medicaid