Provider Demographics
NPI:1851518658
Name:JB PODIATRIC MEDICINE AND SURGERY PC
Entity Type:Organization
Organization Name:JB PODIATRIC MEDICINE AND SURGERY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JULIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BONDARENKO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:917-699-4139
Mailing Address - Street 1:117 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312-5710
Mailing Address - Country:US
Mailing Address - Phone:917-699-4139
Mailing Address - Fax:
Practice Address - Street 1:1130 BRIGHTON BEACH AVE APT 1CC
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5515
Practice Address - Country:US
Practice Address - Phone:718-648-2707
Practice Address - Fax:347-462-2908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2012-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006041213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02841734Medicaid
NYPK9211Medicare ID - Type Unspecified
NY02841734Medicaid