Provider Demographics
NPI:1568436392
Name:KORMYLO, EDWARD J (DPM)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:KORMYLO
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 1:14 WALL ST FL 9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10005-2178
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:33 MEDFORD AVE STE D
Practice Address - Street 2:
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-1222
Practice Address - Country:US
Practice Address - Phone:631-687-4190
Practice Address - Fax:631-687-4199
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-16
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003100213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY480015120OtherMEDICARE RAILROAD
NY00588743Medicaid
NY00588743Medicaid
NYP34161Medicare PIN