Provider Demographics
NPI:1083624209
Name:MISTRETTA, CHARLES W (DPM)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:W
Last Name:MISTRETTA
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 1:23 IVY ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-8212
Mailing Address - Country:US
Mailing Address - Phone:716-664-9698
Mailing Address - Fax:716-661-3851
Practice Address - Street 1:23 IVY ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-8212
Practice Address - Country:US
Practice Address - Phone:716-664-9698
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-09
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN4011213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00957731Medicaid
NYAA1409OtherMEDICARE-PTAN
NYT26688Medicare UPIN