Provider Demographics
NPI:1457355224
Name:WILANTEWICZ, ANDREW STEPHEN (DPM)
Entity Type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:STEPHEN
Last Name:WILANTEWICZ
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:282 NEW HACKENSACK RD
Mailing Address - Street 2:
Mailing Address - City:WAPPINGERS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12590-1402
Mailing Address - Country:US
Mailing Address - Phone:845-462-8637
Mailing Address - Fax:845-462-1140
Practice Address - Street 1:282 NEW HACKENSACK RD
Practice Address - Street 2:
Practice Address - City:WAPPINGERS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12590-1402
Practice Address - Country:US
Practice Address - Phone:845-462-8637
Practice Address - Fax:845-462-1140
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005494213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02062119Medicaid
NYU79350Medicare UPIN
NY02062119Medicaid
NY4227600001Medicare NSC