Provider Demographics
NPI:1861462269
Name:GOETZ, JAMES
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:
Last Name:GOETZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:81 W BAYBERRY RD
Mailing Address - Street 2:
Mailing Address - City:ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11751-4912
Mailing Address - Country:US
Mailing Address - Phone:631-277-8720
Mailing Address - Fax:631-277-8739
Practice Address - Street 1:1428 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:N BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-1611
Practice Address - Country:US
Practice Address - Phone:631-586-3388
Practice Address - Fax:631-586-3394
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004737213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01236960Medicaid
NYP53381Medicare PIN
NYU18053Medicare UPIN