Healthcare Provider Details

I. General information

NPI: 1972938512
Provider Name (Legal Business Name): GLENWOOD PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/12/2013
Last Update Date: 11/07/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6216 MYRTLE AVE
GLENDALE NY
11385-6236
US

IV. Provider business mailing address

6216 MYRTLE AVE
GLENDALE NY
11385-6236
US

V. Phone/Fax

Practice location:
  • Phone: 718-821-2161
  • Fax: 718-821-1252
Mailing address:
  • Phone: 718-821-2161
  • Fax: 718-821-1252

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN004970
License Number StateNY

VIII. Authorized Official

Name: DR. JEFFREY H STARK
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 718-821-2161