Provider Demographics
NPI:1669838033
Name:DIABETIC FOOT & ANKLE CENTERS OF NJ LLC
Entity Type:Organization
Organization Name:DIABETIC FOOT & ANKLE CENTERS OF NJ LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SIMON
Authorized Official - Middle Name:
Authorized Official - Last Name:BECKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:973-736-4030
Mailing Address - Street 1:667 EAGLE ROCK AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07052-2177
Mailing Address - Country:US
Mailing Address - Phone:973-736-4030
Mailing Address - Fax:
Practice Address - Street 1:667 EAGLE ROCK AVE
Practice Address - Street 2:
Practice Address - City:WEST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07052-2177
Practice Address - Country:US
Practice Address - Phone:973-736-4030
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-14
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6702805Medicaid
745398Medicare PIN
NJ6702805Medicaid