Provider Demographics
NPI:1851472419
Name:NY FOOT & ANKLE SPECIALIST DPM PC
Entity Type:Organization
Organization Name:NY FOOT & ANKLE SPECIALIST DPM PC
Other - Org Name:NY FOOT & ANKLE SPECIALISTS
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:PETER
Authorized Official - Middle Name:J
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-231-1401
Mailing Address - Street 1:620 SUFFOLK AVE
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717-4306
Mailing Address - Country:US
Mailing Address - Phone:631-231-1401
Mailing Address - Fax:631-273-0125
Practice Address - Street 1:620 SUFFOLK AVE
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717
Practice Address - Country:US
Practice Address - Phone:631-231-1401
Practice Address - Fax:631-273-0125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-18
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005635213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
5831210001Medicare NSC
NYPDWH41Medicare PIN
NYU79724Medicare UPIN