Provider Demographics
NPI:1649444100
Name:DIVERSIFIED ORTHOTICS
Entity type:Organization
Organization Name:DIVERSIFIED ORTHOTICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ORTHOTIST
Authorized Official - Prefix:MR
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:ALFRED
Authorized Official - Last Name:ROSE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:718-409-6280
Mailing Address - Street 1:3146 E TREMONT AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10461-5706
Mailing Address - Country:US
Mailing Address - Phone:718-409-6280
Mailing Address - Fax:718-409-4110
Practice Address - Street 1:3146 E TREMONT AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5706
Practice Address - Country:US
Practice Address - Phone:718-409-6280
Practice Address - Fax:718-409-4110
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01488857Medicaid
NY0870060001OtherMEDICARE
NY0870060001OtherMEDICARE