Provider Demographics
NPI:1811020571
Name:CHARLES W MISTRETTA, DPM, PC
Entity Type:Organization
Organization Name:CHARLES W MISTRETTA, DPM, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:W
Authorized Official - Last Name:MISTRETTA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:716-664-9698
Mailing Address - Street 1:23 IVY ST
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:14701-8212
Mailing Address - Country:US
Mailing Address - Phone:716-664-9698
Mailing Address - Fax:716-661-3851
Practice Address - Street 1:23 IVY ST
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NY
Practice Address - Zip Code:14701-8212
Practice Address - Country:US
Practice Address - Phone:716-664-9698
Practice Address - Fax:716-661-3851
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004011-1213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02433021Medicaid
NY000500968001OtherBLUE CROSS OF WNY
NY00957731Medicaid
NY00010256401OtherUNIVERA HEALTH CARE
NY8905546OtherINDEPENDENT HEALTH
NY8905546OtherINDEPENDENT HEALTH
NY02433021Medicaid
NYDD3149Medicare ID - Type UnspecifiedUPSTATE MEDICARE DIVISION