Provider Demographics
NPI:1376503763
Name:COUCH, THOMAS E JR (DPM)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:E
Last Name:COUCH
Suffix:JR
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:PO BOX 13694
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12212-3694
Mailing Address - Country:US
Mailing Address - Phone:518-272-0881
Mailing Address - Fax:518-272-0965
Practice Address - Street 1:2121 6TH AVE
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12180-2849
Practice Address - Country:US
Practice Address - Phone:518-272-0881
Practice Address - Fax:518-272-0965
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-28
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002433-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00414622Medicaid
NY00414622Medicaid
NYJ300000185Medicare PIN
NYT26424Medicare UPIN