=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497859664
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AMITYVILLE PODIATRY ASSOCIATES PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/11/2006
-----------------------------------------------------
Last Update Date | 04/25/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 77 BROADWAY
-----------------------------------------------------
City | AMITYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11701
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-691-6060
-----------------------------------------------------
Fax | 631-691-0920
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 77 BROADWAY SUITE 6
-----------------------------------------------------
City | AMITYVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11701-2785
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-691-6060
-----------------------------------------------------
Fax | 631-691-0920
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PODIATRIST PRESIDENT
-----------------------------------------------------
Name | DR. EDWARD LEONARD DAMICO
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 631-691-6060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | N003837
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------