Provider Demographics
NPI:1629116280
Name:FRED WARREN DPM PC
Entity Type:Organization
Organization Name:FRED WARREN DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM,PC
Authorized Official - Phone:718-261-7373
Mailing Address - Street 1:152-74 JEWEL AVE
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1436
Mailing Address - Country:US
Mailing Address - Phone:718-261-7373
Mailing Address - Fax:718-261-7373
Practice Address - Street 1:152-74 JEWEL AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-1436
Practice Address - Country:US
Practice Address - Phone:718-261-7373
Practice Address - Fax:718-261-7373
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-02
Last Update Date:2011-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003300213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP2790041OtherOXFORD
NY47255OtherGHI-HMO
NY00687554Medicaid
NYP35241OtherBLUE CROSS BLUE SHIELD
NMP5309OtherBSBC PPO AND EPO
NYP35241OtherBLUE CROSS BLUE SHIELD
NYP2790041OtherOXFORD
NY4715140001Medicare NSC