Provider Demographics
NPI:1134199599
Name:IMTIYAZ I KAPADWALA DPM PC
Entity type:Organization
Organization Name:IMTIYAZ I KAPADWALA DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:IMTIYAZ
Authorized Official - Middle Name:I
Authorized Official - Last Name:KAPADWALA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-418-8540
Mailing Address - Street 1:1309 HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-2640
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:220A SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4807
Practice Address - Country:US
Practice Address - Phone:171-841-8540
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-26
Last Update Date:2008-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005412174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01808488Medicaid
NYPA1762Medicare PIN
NY01808488Medicaid
NY02734AMedicare PIN
1287760001Medicare NSC