Provider Demographics
NPI:1285369272
Name:NJ MINIMALLY INVASIVE PODIATRIC SURGERY P.C.
Entity type:Organization
Organization Name:NJ MINIMALLY INVASIVE PODIATRIC SURGERY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:ELIGIO
Authorized Official - Last Name:GRULLON
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-598-1184
Mailing Address - Street 1:6400 HUDSON AVE APT 56
Mailing Address - Street 2:
Mailing Address - City:WEST NEW YORK
Mailing Address - State:NJ
Mailing Address - Zip Code:07093-3159
Mailing Address - Country:US
Mailing Address - Phone:201-598-1184
Mailing Address - Fax:
Practice Address - Street 1:1250 E RIDGEWOOD AVE STE 11
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3930
Practice Address - Country:US
Practice Address - Phone:201-701-1595
Practice Address - Fax:212-867-3845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-22
Last Update Date:2022-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty