Provider Demographics
NPI:1760792634
Name:CONEY ISLAND PODIATRY CARE P.C.
Entity Type:Organization
Organization Name:CONEY ISLAND PODIATRY CARE P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:J
Authorized Official - Last Name:DONOVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-769-8400
Mailing Address - Street 1:2753 CONEY ISLAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-5015
Mailing Address - Country:US
Mailing Address - Phone:718-769-8400
Mailing Address - Fax:718-769-3255
Practice Address - Street 1:2753 CONEY ISLAND AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5015
Practice Address - Country:US
Practice Address - Phone:718-769-8400
Practice Address - Fax:718-769-3255
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003550-1213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty