Provider Demographics
NPI:1134117476
Name:TRINIDAD, JOHN R (DPM)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:R
Last Name:TRINIDAD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:193 GREENE AVE
Mailing Address - Street 2:
Mailing Address - City:SAYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11782-3002
Mailing Address - Country:US
Mailing Address - Phone:631-589-1706
Mailing Address - Fax:631-218-1863
Practice Address - Street 1:193 GREENE AVE
Practice Address - Street 2:
Practice Address - City:SAYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11782-3002
Practice Address - Country:US
Practice Address - Phone:631-589-1706
Practice Address - Fax:631-218-1863
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-11
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN002883213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
P3201OtherBC
NY00400189Medicaid
P32011Medicare ID - Type Unspecified
P3201OtherBC
P32012Medicare ID - Type Unspecified