Provider Demographics
NPI:1952314148
Name:NEW IMAGE PODIATRY P.C.
Entity Type:Organization
Organization Name:NEW IMAGE PODIATRY P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LUIS
Authorized Official - Middle Name:A
Authorized Official - Last Name:VIDAL
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:631-864-7380
Mailing Address - Street 1:6143 JERICHO TPKE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-2809
Mailing Address - Country:US
Mailing Address - Phone:631-864-7380
Mailing Address - Fax:631-864-7381
Practice Address - Street 1:6143 JERICHO TPKE
Practice Address - Street 2:SUITE 102
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-2809
Practice Address - Country:US
Practice Address - Phone:631-864-7380
Practice Address - Fax:631-864-7381
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-15
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006167213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02832759Medicaid
NY07800OtherMEDICARE GHI
NYPDWF01OtherNATIONAL GOVERNMENT SERVICES(EMPIRE)