Provider Demographics
NPI:1790854115
Name:SOURIFMAN, HOWARD A (DPM)
Entity Type:Individual
Prefix:DR
First Name:HOWARD
Middle Name:A
Last Name:SOURIFMAN
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 5TH ST
Mailing Address - Street 2:SUITE #2
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-3245
Mailing Address - Country:US
Mailing Address - Phone:732-370-5792
Mailing Address - Fax:
Practice Address - Street 1:314 5TH ST
Practice Address - Street 2:SUITE #2
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-3245
Practice Address - Country:US
Practice Address - Phone:732-370-5792
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00123600213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2012201Medicaid
NJSO540600Medicare ID - Type Unspecified
NJ2012201Medicaid