Provider Demographics
NPI:1679745103
Name:NORTHPORT PODIATRY PC
Entity Type:Organization
Organization Name:NORTHPORT PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PODIATRIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:DENISE
Authorized Official - Middle Name:G
Authorized Official - Last Name:RAIO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-754-3338
Mailing Address - Street 1:1032 FORT SALONGA RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2208
Mailing Address - Country:US
Mailing Address - Phone:631-754-3338
Mailing Address - Fax:631-754-3367
Practice Address - Street 1:1032 FORT SALONGA RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2208
Practice Address - Country:US
Practice Address - Phone:631-754-3338
Practice Address - Fax:631-754-3367
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-25
Last Update Date:2010-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005219213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW3P441OtherMEDICARE PTAN
480034015OtherRR MEDICARE
NY01573528Medicaid
NYW3P441OtherMEDICARE PTAN