Provider Demographics
NPI:1851380778
Name:INNAMORATO, ANTHONY C (DPM)
Entity Type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:C
Last Name:INNAMORATO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:323 LINTON AVE
Mailing Address - Street 2:
Mailing Address - City:LINDENHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11757-6337
Mailing Address - Country:US
Mailing Address - Phone:631-553-4785
Mailing Address - Fax:
Practice Address - Street 1:1555 SUNRISE HWY
Practice Address - Street 2:SUITE 5
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-6027
Practice Address - Country:US
Practice Address - Phone:631-328-1931
Practice Address - Fax:631-328-1930
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-14
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005823-1213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02280500Medicaid
NY05026Medicare PIN
NYU87642Medicare UPIN
NYPG5841Medicare PIN
NY06126IMedicare PIN