Provider Demographics
NPI:1710018007
Name:KNEMOLLER, JEFFREY THOMAS (DPM)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:THOMAS
Last Name:KNEMOLLER
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 HAMBURG TPKE STE 108
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-2033
Mailing Address - Country:US
Mailing Address - Phone:973-925-4111
Mailing Address - Fax:732-873-9114
Practice Address - Street 1:510 HAMBURG TPKE STE 108
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2033
Practice Address - Country:US
Practice Address - Phone:973-925-4111
Practice Address - Fax:973-925-7711
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN0057841213E00000X
NJMD02306213ES0103X
NJ25MD00230600213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ810336Medicare PIN