Provider Demographics
NPI:1285051797
Name:FOOT AND ANKLE CENTER OF FORT LEE PODIATRY
Entity type:Organization
Organization Name:FOOT AND ANKLE CENTER OF FORT LEE PODIATRY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GAVRIIL
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAIMOV
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-363-9844
Mailing Address - Street 1:14402 JEWEL AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1744
Mailing Address - Country:US
Mailing Address - Phone:718-263-3668
Mailing Address - Fax:718-263-0028
Practice Address - Street 1:14402 JEWEL AVE
Practice Address - Street 2:SUITE A
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-1744
Practice Address - Country:US
Practice Address - Phone:718-263-3668
Practice Address - Fax:718-263-0028
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-21
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006045213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty