Healthcare Provider Details

I. General information

NPI: 1245511559
Provider Name (Legal Business Name): LGD PODIATRIC SURGICAL, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2011
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3003 NEW HYDE PARK RD SUITE 312
NEW HYDE PARK NY
11042-1214
US

IV. Provider business mailing address

3003 NEW HYDE PARK RD SUITE 312
NEW HYDE PARK NY
11042-1214
US

V. Phone/Fax

Practice location:
  • Phone: 516-492-3515
  • Fax: 516-492-3516
Mailing address:
  • Phone: 516-492-3515
  • Fax: 516-492-3516

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberN006347
License Number StateNY

VIII. Authorized Official

Name: DR. FRED J DELUCIA
Title or Position: PRESIDENT
Credential: D.P.M.
Phone: 516-492-3515