Healthcare Provider Details

I. General information

NPI: 1104837434
Provider Name (Legal Business Name): BINGHAMTON PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2006
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

38 FRONT ST # 2B
BINGHAMTON NY
13905-4712
US

IV. Provider business mailing address

111 E 14TH ST
ELMIRA HEIGHTS NY
14903-1303
US

V. Phone/Fax

Practice location:
  • Phone: 607-724-1263
  • Fax: 607-724-1263
Mailing address:
  • Phone: 607-734-9539
  • Fax: 607-734-6293

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: GREG WIXSOM
Title or Position: SOLE PROPRIETOR
Credential: D.P.M.
Phone: 607-724-1263