Provider Demographics
NPI:1275653776
Name:MASSAPEQUA PODIATRY ASSOCIATES, P.C.
Entity Type:Organization
Organization Name:MASSAPEQUA PODIATRY ASSOCIATES, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:COREY
Authorized Official - Middle Name:
Authorized Official - Last Name:FOX
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:516-541-9000
Mailing Address - Street 1:4160 MERRICK RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MASSAPEQUA
Mailing Address - State:NY
Mailing Address - Zip Code:11758-6000
Mailing Address - Country:US
Mailing Address - Phone:516-541-9000
Mailing Address - Fax:516-795-8082
Practice Address - Street 1:4160 MERRICK RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-6000
Practice Address - Country:US
Practice Address - Phone:516-541-9000
Practice Address - Fax:516-795-8082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-29
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004833213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4024190001Medicare NSC