Provider Demographics
NPI:1972761435
Name:ANKLE & FOOT SURGERY, PA
Entity type:Organization
Organization Name:ANKLE & FOOT SURGERY, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:PETER
Authorized Official - Last Name:LICOPANTIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:973-331-7900
Mailing Address - Street 1:16 POCONO RD
Mailing Address - Street 2:SUITE 209
Mailing Address - City:DENVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07834-2901
Mailing Address - Country:US
Mailing Address - Phone:973-331-7900
Mailing Address - Fax:973-331-7999
Practice Address - Street 1:16 POCONO RD
Practice Address - Street 2:SUITE 209
Practice Address - City:DENVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07834-2901
Practice Address - Country:US
Practice Address - Phone:973-331-7900
Practice Address - Fax:973-331-7999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-30
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00187700213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0943908Medicaid
NJT88970Medicare UPIN
NJ0943908Medicaid