Healthcare Provider Details

I. General information

NPI: 1174685978
Provider Name (Legal Business Name): KENNETH L. MESEROLE JR. D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PALO ALTO DR
PLAINVIEW NY
11803-5809
US

IV. Provider business mailing address

1 PALO ALTO DR
PLAINVIEW NY
11803-5809
US

V. Phone/Fax

Practice location:
  • Phone: 516-822-0418
  • Fax:
Mailing address:
  • Phone: 516-822-0418
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN004934
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN004934
License Number StateNY

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: