Provider Demographics
NPI:1285689836
Name:SMOOLCA, MARY ELLEN (DPM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:SMOOLCA
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:406 SECOND STREET
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850
Mailing Address - Country:US
Mailing Address - Phone:607-272-9223
Mailing Address - Fax:607-272-7631
Practice Address - Street 1:406 SECOND STREET
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-272-9223
Practice Address - Fax:607-272-7631
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2010-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004281213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0147054BMedicaid
T58812Medicare UPIN
NY0147054BMedicaid