Provider Demographics
NPI:1891972089
Name:MICHAEL L WODKA D.P.M. PC
Entity Type:Organization
Organization Name:MICHAEL L WODKA D.P.M. PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WODKA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:845-692-3338
Mailing Address - Street 1:30 INDUSTRIAL DR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-1662
Mailing Address - Country:US
Mailing Address - Phone:845-692-3338
Mailing Address - Fax:
Practice Address - Street 1:30 INDUSTRIAL DR
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-1662
Practice Address - Country:US
Practice Address - Phone:845-692-3338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-30
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003161-1213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00554738Medicaid
NYP5W041Medicare PIN
NY4697460001Medicare NSC