Healthcare Provider Details

I. General information

NPI: 1740387703
Provider Name (Legal Business Name): SAMUEL B PEARLSTEIN DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 TOWNE DR
FAYETTEVILLE NY
13066-1331
US

IV. Provider business mailing address

512 TOWNE DR
FAYETTEVILLE NY
13066-1331
US

V. Phone/Fax

Practice location:
  • Phone: 315-637-5500
  • Fax: 315-637-5588
Mailing address:
  • Phone: 315-637-5500
  • Fax: 315-637-5588

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN003595-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: