Healthcare Provider Details

I. General information

NPI: 1740342633
Provider Name (Legal Business Name): MICHAEL ALLEN MASIAS D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/15/2006
Last Update Date: 06/04/2020
Certification Date: 06/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34 BROADWAY
RENSSELAER NY
12144-2916
US

IV. Provider business mailing address

PO BOX 162
RENSSELAER NY
12144-0162
US

V. Phone/Fax

Practice location:
  • Phone: 845-210-3597
  • Fax:
Mailing address:
  • Phone: 518-320-8659
  • Fax: 888-382-3932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberN004777
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberN004777
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code213ES0000X
TaxonomySports Medicine Podiatrist
License NumberN004777
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN004777
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: