Healthcare Provider Details

I. General information

NPI: 1184099442
Provider Name (Legal Business Name): COUNTRY FOOT CARE PODIATRY PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 PHYLLIS DR
PATCHOGUE NY
11772-2900
US

IV. Provider business mailing address

173 MINEOLA BLVD SUITE 201
MINEOLA NY
11501-2528
US

V. Phone/Fax

Practice location:
  • Phone: 631-475-3030
  • Fax:
Mailing address:
  • Phone: 516-741-3338
  • Fax: 516-506-7123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: STEVEN BROOK
Title or Position: OWNER
Credential: DPM
Phone: 516-741-3338