Provider Demographics
NPI:1689164584
Name:NORTHEAST FOOT CARE PODIATRY PC
Entity Type:Organization
Organization Name:NORTHEAST FOOT CARE PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:MONICA
Authorized Official - Middle Name:J
Authorized Official - Last Name:MONTALVO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:845-641-4783
Mailing Address - Street 1:16 SEMINARA CIR
Mailing Address - Street 2:
Mailing Address - City:GARNERVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10923-1736
Mailing Address - Country:US
Mailing Address - Phone:845-641-4783
Mailing Address - Fax:
Practice Address - Street 1:16 SEMINARA CIR
Practice Address - Street 2:
Practice Address - City:GARNERVILLE
Practice Address - State:NY
Practice Address - Zip Code:10923
Practice Address - Country:US
Practice Address - Phone:845-641-4783
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-16
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006820261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400176602OtherMEDICARE
NY04816428Medicaid