Provider Demographics
NPI:1023189842
Name:MONROE PODIATRY GROUP
Entity Type:Organization
Organization Name:MONROE PODIATRY GROUP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:RAYMOND
Authorized Official - Middle Name:
Authorized Official - Last Name:DIVASTO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:585-872-6520
Mailing Address - Street 1:45 NORTH AVE
Mailing Address - Street 2:
Mailing Address - City:WEBSTER
Mailing Address - State:NY
Mailing Address - Zip Code:14580-3054
Mailing Address - Country:US
Mailing Address - Phone:585-872-6520
Mailing Address - Fax:585-872-6357
Practice Address - Street 1:45 NORTH AVE
Practice Address - Street 2:
Practice Address - City:WEBSTER
Practice Address - State:NY
Practice Address - Zip Code:14580-3054
Practice Address - Country:US
Practice Address - Phone:585-872-6520
Practice Address - Fax:585-872-6357
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY213ES0131X
332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG0188302590OtherEXCELLUS BLUECROSS
NY0975080001Medicare NSC