Healthcare Provider Details

I. General information

NPI: 1689795890
Provider Name (Legal Business Name): INNOVATIVE FOOTCARE P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 09/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

391 E 149TH ST
BRONX NY
10455-3907
US

IV. Provider business mailing address

391 E 149TH ST
BRONX NY
10455-3907
US

V. Phone/Fax

Practice location:
  • Phone: 718-292-7081
  • Fax:
Mailing address:
  • Phone: 718-292-7081
  • Fax: 718-292-7094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN004738
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN005916
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN003762
License Number StateNY

VIII. Authorized Official

Name: DR. ROBERT MATTHEW LOCASTRO
Title or Position: DOCTOR
Credential: DPM
Phone: 718-292-7081