Provider Demographics
NPI:1720318652
Name:IREBO FOOT AND ANKLE SURGERY
Entity Type:Organization
Organization Name:IREBO FOOT AND ANKLE SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:OLUTUNDE
Authorized Official - Middle Name:AINA
Authorized Official - Last Name:SHONIREGUN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:646-633-1045
Mailing Address - Street 1:1316 E 83RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-5102
Mailing Address - Country:US
Mailing Address - Phone:646-633-1045
Mailing Address - Fax:
Practice Address - Street 1:444 WILLIS AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10455-4013
Practice Address - Country:US
Practice Address - Phone:646-633-1045
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-12-24
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006322261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric