Provider Demographics
NPI:1639235468
Name:MENACHEM, GARY DENNIS (DPM)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:DENNIS
Last Name:MENACHEM
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 1:6809 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11367-1310
Mailing Address - Country:US
Mailing Address - Phone:718-261-3718
Mailing Address - Fax:718-261-3735
Practice Address - Street 1:6809 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11367-1310
Practice Address - Country:US
Practice Address - Phone:718-261-3718
Practice Address - Fax:718-261-3735
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN3269213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00698320Medicaid
NYT32112Medicare UPIN
NY00698320Medicaid