Provider Demographics
NPI:1851115851
Name:PRIME PODIATRY LLC
Entity type:Organization
Organization Name:PRIME PODIATRY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELIAS
Authorized Official - Middle Name:GEORGE
Authorized Official - Last Name:LOGOTHETIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:973-934-9704
Mailing Address - Street 1:91 ROSELAND AVE UNIT C10
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-5970
Mailing Address - Country:US
Mailing Address - Phone:973-934-9704
Mailing Address - Fax:
Practice Address - Street 1:64 US HIGHWAY 46 STE 201
Practice Address - Street 2:
Practice Address - City:PINE BROOK
Practice Address - State:NJ
Practice Address - Zip Code:07058-4401
Practice Address - Country:US
Practice Address - Phone:973-934-9704
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-11-14
Last Update Date:2025-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric