Provider Demographics
NPI:1710306501
Name:NEW AGE FOOT AND ANKLE PODIATRY PC
Entity Type:Organization
Organization Name:NEW AGE FOOT AND ANKLE PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALEKSANDER
Authorized Official - Middle Name:VALENTINOVICH
Authorized Official - Last Name:LAVRENOV
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:917-687-7528
Mailing Address - Street 1:20548 VENTURA BLVD
Mailing Address - Street 2:SUITE 217
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91364-6225
Mailing Address - Country:US
Mailing Address - Phone:917-687-7528
Mailing Address - Fax:
Practice Address - Street 1:16935 VANOWEN ST
Practice Address - Street 2:SUITE E
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-4595
Practice Address - Country:US
Practice Address - Phone:917-687-7528
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-09
Last Update Date:2014-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE 5019213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty