Provider Demographics
NPI:1417950866
Name:GROSSMAN, MYLES (DPM)
Entity Type:Individual
Prefix:DR
First Name:MYLES
Middle Name:
Last Name:GROSSMAN
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 1:2174 HEWLETT AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:MERRICK
Mailing Address - State:NY
Mailing Address - Zip Code:11566-3620
Mailing Address - Country:US
Mailing Address - Phone:516-379-2560
Mailing Address - Fax:516-546-8845
Practice Address - Street 1:2174 HEWLETT AVE
Practice Address - Street 2:STE 202
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3620
Practice Address - Country:US
Practice Address - Phone:516-379-2560
Practice Address - Fax:516-546-8845
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2012-10-05
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
NYN004096213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00985117Medicaid
NYP43172Medicare PIN
NY00985117Medicaid
NYP43171Medicare PIN
NYT51343Medicare UPIN