Provider Demographics
NPI:1902839830
Name:BORRELLI, HENRY (DPM)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:
Last Name:BORRELLI
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 1:366 UPPER MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07043-1436
Mailing Address - Country:US
Mailing Address - Phone:732-968-3900
Mailing Address - Fax:732-968-3944
Practice Address - Street 1:309 ROCK AVE
Practice Address - Street 2:
Practice Address - City:GREEN BROOK
Practice Address - State:NJ
Practice Address - Zip Code:08812-2616
Practice Address - Country:US
Practice Address - Phone:732-968-3900
Practice Address - Fax:732-968-3944
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00227300213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7451008Medicaid
NJ722584Medicare ID - Type Unspecified
NJ7451008Medicaid