Provider Demographics
NPI:1962722983
Name:JAY MUKKER DPM INC
Entity type:Organization
Organization Name:JAY MUKKER DPM INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MUKKER
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:559-224-5101
Mailing Address - Street 1:7210 N MILBURN AVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-0022
Mailing Address - Country:US
Mailing Address - Phone:559-224-5101
Mailing Address - Fax:559-224-4396
Practice Address - Street 1:7210 N MILBURN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-0022
Practice Address - Country:US
Practice Address - Phone:559-224-5101
Practice Address - Fax:559-224-4396
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-02
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE4656213ES0103X
CAE46560332B00000X, 332BC3200X, 335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
No335E00000XSuppliersProsthetic/Orthotic SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000E46560Medicaid
CAV11924Medicare UPIN
CA6389800001Medicare NSC
CA000E46560Medicare PIN
CA000E46560Medicaid