Provider Demographics
NPI:1639699325
Name:PROACTIVE FOOT AND ANKLE
Entity Type:Organization
Organization Name:PROACTIVE FOOT AND ANKLE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GEWIRTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-391-1113
Mailing Address - Street 1:74 PASCACK RD STE 6
Mailing Address - Street 2:
Mailing Address - City:PARK RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07656-1942
Mailing Address - Country:US
Mailing Address - Phone:201-391-1113
Mailing Address - Fax:
Practice Address - Street 1:74 PASCACK RD STE 6
Practice Address - Street 2:
Practice Address - City:PARK RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07656-1942
Practice Address - Country:US
Practice Address - Phone:201-391-1113
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-22
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty