Healthcare Provider Details

I. General information

NPI: 1407909039
Provider Name (Legal Business Name): GREEN MOUNTAIN FAMILY PODIATRY PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 06/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

212 BROADWAY
WHITEHALL NY
12887-1639
US

IV. Provider business mailing address

212 BROADWAY
WHITEHALL NY
12887-1639
US

V. Phone/Fax

Practice location:
  • Phone: 518-499-9264
  • Fax: 518-499-9247
Mailing address:
  • Phone: 518-499-9264
  • Fax: 518-499-9247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number003568
License Number StateNY

VIII. Authorized Official

Name: DR. JOSE GUILLERMO IRIZARRY
Title or Position: OWNER-PRESIDENT
Credential: D.P.M.
Phone: 518-499-9264