Provider Demographics
NPI:1851377907
Name:CONCILLA, J KURT (DPM)
Entity Type:Individual
Prefix:
First Name:J
Middle Name:KURT
Last Name:CONCILLA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:3229 E GENESEE ST
Mailing Address - Street 2:JOSLIN CENTER
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13214-2016
Mailing Address - Country:US
Mailing Address - Phone:315-464-5726
Mailing Address - Fax:315-464-2500
Practice Address - Street 1:3229 E GENESEE ST
Practice Address - Street 2:JOSLIN CENTER
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13214-2016
Practice Address - Country:US
Practice Address - Phone:315-464-5726
Practice Address - Fax:315-464-2500
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2014-02-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NYN003073213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01704741Medicaid
NY01704741Medicaid
NYJ400114645Medicare PIN
P00255383Medicare PIN
T58750Medicare UPIN