Provider Demographics
NPI:1639304249
Name:ESTRADA PODIATRY GROUP LLC
Entity Type:Organization
Organization Name:ESTRADA PODIATRY GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEXANDER
Authorized Official - Middle Name:
Authorized Official - Last Name:ESTRADA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-865-3400
Mailing Address - Street 1:5005 BERGENLINE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-5563
Mailing Address - Country:US
Mailing Address - Phone:201-865-3400
Mailing Address - Fax:201-520-0040
Practice Address - Street 1:5005 BERGENLINE AVE
Practice Address - Street 2:
Practice Address - City:WEST NEW YORK
Practice Address - State:NJ
Practice Address - Zip Code:07093-5563
Practice Address - Country:US
Practice Address - Phone:201-865-3400
Practice Address - Fax:201-520-0040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-27
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00268900213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0056553Medicaid
NJP00353274OtherPALMETTO GBA
NJU92478Medicare UPIN
NJ0056553Medicaid