Provider Demographics
NPI:1720805526
Name:BOLTROPE PODIATRY NY PLLC
Entity type:Organization
Organization Name:BOLTROPE PODIATRY NY PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:GEWIRTZ
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:201-391-1113
Mailing Address - Street 1:201 STATE RT 17 STE 604
Mailing Address - Street 2:
Mailing Address - City:RUTHERFORD
Mailing Address - State:NJ
Mailing Address - Zip Code:07070-2905
Mailing Address - Country:US
Mailing Address - Phone:201-571-0214
Mailing Address - Fax:
Practice Address - Street 1:3117 DITMARS BLVD
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2300
Practice Address - Country:US
Practice Address - Phone:718-274-4040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-23
Last Update Date:2024-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07680188Medicaid