Provider Demographics
NPI:1447419155
Name:PODIATRY SERVICES OF ITHACA P.C.
Entity Type:Organization
Organization Name:PODIATRY SERVICES OF ITHACA P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:O
Authorized Official - Last Name:VILLAGONZALO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:607-257-8877
Mailing Address - Street 1:2255 N TRIPHAMMER RD
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1576
Mailing Address - Country:US
Mailing Address - Phone:607-257-8877
Mailing Address - Fax:607-257-8879
Practice Address - Street 1:2255 N TRIPHAMMER RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1576
Practice Address - Country:US
Practice Address - Phone:607-257-8877
Practice Address - Fax:607-257-8879
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2020-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005881213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03034237Medicaid
FL3130290001OtherARC
NY02862408Medicaid
FL3130290001OtherARC