Provider Demographics
NPI:1457367724
Name:AMICO, SUSAN (DPM)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:AMICO
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:62 SEGUINE AVE STE 2
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10309-3723
Mailing Address - Country:US
Mailing Address - Phone:718-317-7740
Mailing Address - Fax:
Practice Address - Street 1:62 SEGUINE AVE STE 2
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10309-3723
Practice Address - Country:US
Practice Address - Phone:718-317-7740
Practice Address - Fax:718-948-1090
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-31
Last Update Date:2022-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN003694213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00903599Medicaid
NYP40391Medicare PIN
NY00903599Medicaid