Provider Demographics
NPI:1770526774
Name:BRODY, MICHAEL LAWRENCE (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:LAWRENCE
Last Name:BRODY
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 1:6 EDSCHO LN
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-4806
Mailing Address - Country:US
Mailing Address - Phone:631-549-3668
Mailing Address - Fax:631-547-1423
Practice Address - Street 1:56340 MAIN ROAD
Practice Address - Street 2:
Practice Address - City:SOUTHOLD
Practice Address - State:NY
Practice Address - Zip Code:11971
Practice Address - Country:US
Practice Address - Phone:631-549-3668
Practice Address - Fax:631-547-1423
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004211213ES0000X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0000XPodiatric Medicine & Surgery Service ProvidersPodiatristSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP45301Medicare UPIN
NYT51437Medicare UPIN