Provider Demographics
NPI:1407909039
Name:GREEN MOUNTAIN FAMILY PODIATRY PC
Entity Type:Organization
Organization Name:GREEN MOUNTAIN FAMILY PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSE
Authorized Official - Middle Name:GUILLERMO
Authorized Official - Last Name:IRIZARRY
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:518-499-9264
Mailing Address - Street 1:212 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:NY
Mailing Address - Zip Code:12887-1639
Mailing Address - Country:US
Mailing Address - Phone:518-499-9264
Mailing Address - Fax:518-499-9247
Practice Address - Street 1:212 BROADWAY
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:NY
Practice Address - Zip Code:12887-1639
Practice Address - Country:US
Practice Address - Phone:518-499-9264
Practice Address - Fax:518-499-9247
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-18
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003568213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000470542001OtherBLUESHIELD HEALTHNOW
NY9659860-99OtherGHI
NY041210000033OtherFIDELIS
NYP3899OtherEMPIRE BLUE CROSS
VT00028868OtherBCBS VERMONT
VT1005566OtherVERMONT MEDICAID
NY00810586Medicaid
NY59591OtherMVP HEALTH CARE
NYPAW48OtherEMPIRE BLUE CROSS
NY000470542001OtherBLUESHIELD HEALTHNOW
NY00810586Medicaid
T51187Medicare UPIN
NY59591OtherMVP HEALTH CARE