Basic Information
Provider Information | |||||||||
NPI: | 1598771107 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BORNSTEIN | ||||||||
FirstName: | GERALD | ||||||||
MiddleName: | B | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BORNSTEIN | ||||||||
OtherFirstName: | JAY | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DPM | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 833 CHESTNUT ST STE 520 | ||||||||
Address2: |   | ||||||||
City: | PHILADELPHIA | ||||||||
State: | PA | ||||||||
PostalCode: | 191074430 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6096777003 | ||||||||
FaxNumber: | 2673393761 | ||||||||
Practice Location | |||||||||
Address1: | 255 N LAKEMONT AVE STE 207 | ||||||||
Address2: |   | ||||||||
City: | WINTER PARK | ||||||||
State: | FL | ||||||||
PostalCode: | 327923219 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8444074070 | ||||||||
FaxNumber: | 4077433050 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/01/2006 | ||||||||
LastUpdateDate: | 07/06/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/06/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | PO1564 | FL | N |   | Podiatric Medicine & Surgery Service Providers | Podiatrist |   | 213ES0103X | PO1564 | FL | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | 260921500 | 05 | FL |   | MEDICAID |