Provider Demographics
NPI:1497819247
Name:KOLK, EDWARD WILLIAM (DPM)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:WILLIAM
Last Name:KOLK
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 1:39 NEW HAMPSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-2507
Mailing Address - Country:US
Mailing Address - Phone:631-273-4699
Mailing Address - Fax:631-273-4699
Practice Address - Street 1:39 NEW HAMPSHIRE AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-2507
Practice Address - Country:US
Practice Address - Phone:631-273-4699
Practice Address - Fax:631-273-4699
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2011-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004109213E00000X
NY309257163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA480008349Medicare ID - Type UnspecifiedLI RAIL ROAD MEDICARE
T51366Medicare UPIN
NYP43651Medicare ID - Type UnspecifiedPODIATRIST