Provider Demographics
NPI:1013953926
Name:PORT WASHINGTON PODIATRY INC
Entity Type:Organization
Organization Name:PORT WASHINGTON PODIATRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BONGIORNO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:262-284-8800
Mailing Address - Street 1:2132 WILLOW POND WAY
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WI
Mailing Address - Zip Code:53024-9102
Mailing Address - Country:US
Mailing Address - Phone:262-284-8800
Mailing Address - Fax:262-284-8861
Practice Address - Street 1:1317 W GRAND AVENUE
Practice Address - Street 2:PORT WASHINGTON PODIATRY
Practice Address - City:PORT WASHINGTON
Practice Address - State:WI
Practice Address - Zip Code:53074
Practice Address - Country:US
Practice Address - Phone:262-284-8800
Practice Address - Fax:262-284-8861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-20
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI798025213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DB0746OtherRR MCR
WI43268200Medicaid
=========014OtherBLUE CROSS
=========014OtherBLUE CROSS
WI43268200Medicaid