Organization Name: | LONG ISLAND PODIATRY PC |
NPI Number: | 1063669430 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | MICHAEL LAWRENCE BRODY (PRESIDENT) |
Mailing Address: | 56340 Main Road Southold |
State: | NY US |
Postal Code: | 117253805 |
Phone Number: | 6317652772 |
Fax Number: | |
NPI Enumeration Date: | 08/27/2008 |
NPI Last Update Date: | 04/10/2013 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 213EP1101X |
License Number: | N004211 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | NY |
Taxonomy Type: | Podiatric Medicine & Surgery Service Providers |
Taxonomy Classification: | Podiatrist |
Taxonomy Specialization: | Primary Podiatric Medicine |
Taxonomy Definition: |