Provider Demographics
NPI:1891704235
Name:M D FOOTWEAR CORPORATION
Entity Type:Organization
Organization Name:M D FOOTWEAR CORPORATION
Other - Org Name:THE RUGGED BOOT
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:J
Authorized Official - Last Name:HIRSHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:631-471-2668
Mailing Address - Street 1:2061 MIDDLE COUNTRY RD
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-3518
Mailing Address - Country:US
Mailing Address - Phone:631-471-2668
Mailing Address - Fax:631-471-4769
Practice Address - Street 1:2061 MIDDLE COUNTRY RD
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-3518
Practice Address - Country:US
Practice Address - Phone:631-471-2668
Practice Address - Fax:631-471-4769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-05
Last Update Date:2010-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY=========OtherTAX ID NUMBER
NY5038650001Medicare ID - Type UnspecifiedMEDICARE