Provider Demographics
NPI:1518203108
Name:J. KURT CONCILLA, D.P.M., PLLC
Entity Type:Organization
Organization Name:J. KURT CONCILLA, D.P.M., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:KURT
Authorized Official - Last Name:CONCILLA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:315-200-6817
Mailing Address - Street 1:4567 CROSSROADS PARK DR
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13088-3589
Mailing Address - Country:US
Mailing Address - Phone:315-295-2100
Mailing Address - Fax:
Practice Address - Street 1:2926 W LAKE RD
Practice Address - Street 2:
Practice Address - City:CAZENOVIA
Practice Address - State:NY
Practice Address - Zip Code:13035-9818
Practice Address - Country:US
Practice Address - Phone:315-200-6817
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-12-31
Last Update Date:2012-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003073213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty