Provider Demographics
NPI:1083885461
Name:DANIEL KORMYLO, DPM
Entity Type:Organization
Organization Name:DANIEL KORMYLO, DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:KORMYLO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-744-8282
Mailing Address - Street 1:PO BOX 5153
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-0969
Mailing Address - Country:US
Mailing Address - Phone:631-744-8282
Mailing Address - Fax:631-821-5583
Practice Address - Street 1:745 ROUTE 25A
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-9552
Practice Address - Country:US
Practice Address - Phone:631-744-8282
Practice Address - Fax:631-821-5583
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DANIEL KORMYLO, DPM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-13
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004250332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYT51457Medicare UPIN
NY1049990002Medicare NSC