Provider Demographics
NPI:1811254725
Name:CLOUTIER-CHAMPAGNE, LAURENCE (DPM)
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:
Last Name:CLOUTIER-CHAMPAGNE
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 1:60 MADISON AVE
Mailing Address - Street 2:5TH
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-1600
Mailing Address - Country:US
Mailing Address - Phone:212-545-2400
Mailing Address - Fax:
Practice Address - Street 1:81 W 115TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-3138
Practice Address - Country:US
Practice Address - Phone:212-426-0088
Practice Address - Fax:212-426-8367
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-16
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006470-1213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NY331947Medicare Oscar/Certification
NY00695941Medicaid
NYG100000410Medicare Oscar/Certification
NYW6L111Medicare Oscar/Certification
NY331946Medicare Oscar/Certification