Provider Demographics
NPI:1427154988
Name:REALE, MARTIN FRANCIS (DPM)
Entity type:Individual
Prefix:
First Name:MARTIN
Middle Name:FRANCIS
Last Name:REALE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 DRIFTWOOD COURT
Mailing Address - Street 2:
Mailing Address - City:GLASSBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08028-2846
Mailing Address - Country:US
Mailing Address - Phone:856-697-9090
Mailing Address - Fax:
Practice Address - Street 1:1335 W TABOR RD
Practice Address - Street 2:SUITE 302
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3038
Practice Address - Country:US
Practice Address - Phone:856-697-9090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00134100213E00000X
PASC002395L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA000849408Medicaid
NJ1661001Medicaid
PA185211OtherLICENSE
PASC002395LOtherLICENSE
PA0496500001Medicare NSC
PA185211OtherLICENSE
PA000849408Medicaid
NJRE453486Medicare PIN