Healthcare Provider Details

I. General information

NPI: 1659848802
Provider Name (Legal Business Name): EAST PATCHOGUE PODIATRY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2018
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

283 COMMACK RD STE 125
COMMACK NY
11725-3447
US

IV. Provider business mailing address

285 SILLS RD BLDG 17
EAST PATCHOGUE NY
11772-4808
US

V. Phone/Fax

Practice location:
  • Phone: 631-499-3505
  • Fax:
Mailing address:
  • Phone: 631-654-5566
  • Fax: 631-654-8250

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: EDWARD J KORMYLO
Title or Position: PODIATRIST/OWNER
Credential: DPM
Phone: 631-654-5566