Healthcare Provider Details

I. General information

NPI: 1063669430
Provider Name (Legal Business Name): LONG ISLAND PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/27/2008
Last Update Date: 04/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56340 MAIN ROAD
SOUTHOLD NY
11725-3805
US

IV. Provider business mailing address

5 EVELYN DR
COMMACK NY
11725-3805
US

V. Phone/Fax

Practice location:
  • Phone: 631-765-2772
  • Fax:
Mailing address:
  • Phone: 631-549-3668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberN004211
License Number StateNY

VIII. Authorized Official

Name: DR. MICHAEL LAWRENCE BRODY
Title or Position: PRESIDENT
Credential: DPM
Phone: 631-549-3668