Provider Demographics
NPI:1396875365
Name:PODIATRYCARE P C
Entity type:Organization
Organization Name:PODIATRYCARE P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT-OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:MARRA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:860-741-3041
Mailing Address - Street 1:1379 ENFIELD ST
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-5524
Mailing Address - Country:US
Mailing Address - Phone:860-741-3041
Mailing Address - Fax:860-741-5644
Practice Address - Street 1:1379 ENFIELD ST
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-5524
Practice Address - Country:US
Practice Address - Phone:860-741-3041
Practice Address - Fax:860-741-5644
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-07
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000303213ES0103X
CT000731213ES0103X
CTP00373213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
C00510Medicare PIN
CT0240710001Medicare NSC