Provider Demographics
NPI:1629732086
Name:TOMS RIVER PODIATRIST
Entity Type:Organization
Organization Name:TOMS RIVER PODIATRIST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:
Authorized Official - Last Name:DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:732-814-7029
Mailing Address - Street 1:104 COMMONS WAY BLDG A
Mailing Address - Street 2:
Mailing Address - City:TOMS RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08755-6426
Mailing Address - Country:US
Mailing Address - Phone:732-349-1123
Mailing Address - Fax:732-349-6549
Practice Address - Street 1:104 COMMONS WAY BLDG A
Practice Address - Street 2:
Practice Address - City:TOMS RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08755-6426
Practice Address - Country:US
Practice Address - Phone:732-349-1123
Practice Address - Fax:732-349-6549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-10-22
Last Update Date:2021-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0231622Medicaid