Provider Demographics
NPI:1023299674
Name:MODERN PODIATRIC CARE P.C
Entity type:Organization
Organization Name:MODERN PODIATRIC CARE P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAN
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:C
Authorized Official - Last Name:NWAKANMA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-465-3040
Mailing Address - Street 1:11620 190TH ST
Mailing Address - Street 2:
Mailing Address - City:SAINT ALBANS
Mailing Address - State:NY
Mailing Address - Zip Code:11412-3132
Mailing Address - Country:US
Mailing Address - Phone:718-465-3040
Mailing Address - Fax:
Practice Address - Street 1:9204 SPRINGFIELD BLVD
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1857
Practice Address - Country:US
Practice Address - Phone:718-465-3040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-23
Last Update Date:2009-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005629213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01984110Medicaid
NYU76147Medicare UPIN
NY07583Medicare PIN
NYPUW071Medicare PIN