Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 213EP1101X | Primary Podiatric Medicine | 25MD00228700 | NJ |
NPI | 1386674273 |
---|---|
Provider Name | Melrose Blake-Bethea |
First Address | Irvington, NJ 07111-2955 |
Second Address | Irvington, NJ 07111-2955 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/07/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
25MD00228700 | PODIATRY LICENSE (01) | NJ |
DO7146200 | CDS PODIATRY (01) | NJ |