Provider Demographics
NPI:1497859664
Name:AMITYVILLE PODIATRY ASSOCIATES PC
Entity Type:Organization
Organization Name:AMITYVILLE PODIATRY ASSOCIATES PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:LEONARD
Authorized Official - Last Name:DAMICO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-691-6060
Mailing Address - Street 1:77 BROADWAY
Mailing Address - Street 2:SUITE 6
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2785
Mailing Address - Country:US
Mailing Address - Phone:631-691-6060
Mailing Address - Fax:631-691-0920
Practice Address - Street 1:77 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701
Practice Address - Country:US
Practice Address - Phone:631-691-6060
Practice Address - Fax:631-691-0920
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2014-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003837213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00907960Medicaid
P39921Medicare ID - Type Unspecified
NY00907960Medicaid
NY4076180001Medicare NSC