Provider Demographics
NPI:1518078708
Name:MOHAWK VALLEY PODIATRY PC
Entity Type:Organization
Organization Name:MOHAWK VALLEY PODIATRY PC
Other - Org Name:DR ROBERT C DICAPRIO, JR
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:CARL
Authorized Official - Last Name:DICAPRIO
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:518-853-3999
Mailing Address - Street 1:PO BOX 427
Mailing Address - Street 2:
Mailing Address - City:FULTONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12072-0427
Mailing Address - Country:US
Mailing Address - Phone:518-853-3999
Mailing Address - Fax:518-374-1818
Practice Address - Street 1:19 MAIN ST
Practice Address - Street 2:
Practice Address - City:FULTONVILLE
Practice Address - State:NY
Practice Address - Zip Code:12072-0427
Practice Address - Country:US
Practice Address - Phone:518-853-3999
Practice Address - Fax:518-374-1818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004755213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
54134OtherMVP
NYP114421OtherBLUE CROSS
10000492OtherCDPHP
NY000448056003OtherBLUE SHIELD
NY01554094Medicaid
54134OtherMVP
NYAA1139Medicare ID - Type Unspecified
NY5977870001Medicare NSC