Provider Demographics
NPI:1467736603
Name:SKONIECZNY, MICHAEL J (DPM)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:SKONIECZNY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:DR
Other - First Name:MICHAEL
Other - Middle Name:J
Other - Last Name:SKONIECZNY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DPM
Mailing Address - Street 1:116 COURT ST STE 3
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-8710
Mailing Address - Country:US
Mailing Address - Phone:508-747-1973
Mailing Address - Fax:
Practice Address - Street 1:116 COURT ST STE 3
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-8710
Practice Address - Country:US
Practice Address - Phone:508-747-1973
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILPR00101213E00000X
NY006630213E00000X
MA2448213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RIRES000Medicare UPIN
NYA400103576Medicare PIN