Provider Demographics
NPI:1912977364
Name:KAPADWALA, IMTIYAZ I (DPM)
Entity Type:Individual
Prefix:DR
First Name:IMTIYAZ
Middle Name:I
Last Name:KAPADWALA
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 1:1309 HARBOR RD
Mailing Address - Street 2:
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-2640
Mailing Address - Country:US
Mailing Address - Phone:718-418-8540
Mailing Address - Fax:
Practice Address - Street 1:220A SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4807
Practice Address - Country:US
Practice Address - Phone:718-418-8540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-26
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005412213ES0131X
NYNOO5412213ES0131X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01808488Medicaid
NY01808488Medicaid
NYU69701Medicare UPIN
NYPA1762Medicare PIN
NY1287760001Medicare NSC
NYPA1762Medicare PIN