Provider Demographics
NPI:1346226909
Name:KASSNOVE, MATTHEW (DPM)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:
Last Name:KASSNOVE
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 1:28 DEEPDALE DR
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5506
Mailing Address - Country:US
Mailing Address - Phone:631-462-0060
Mailing Address - Fax:
Practice Address - Street 1:440 WAVERLY AVE STE 3
Practice Address - Street 2:SUITE 3
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1597
Practice Address - Country:US
Practice Address - Phone:631-654-3838
Practice Address - Fax:631-654-3832
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-15
Last Update Date:2013-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005591213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02354814-5Medicaid
NYPG2611Medicare ID - Type Unspecified
NYPG2613Medicare ID - Type Unspecified
NYPH4211Medicare ID - Type Unspecified
NY02354814-5Medicaid
NYPH4212Medicare ID - Type Unspecified