=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689171324
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KINGS PARK PODIATRY PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2018
-----------------------------------------------------
Last Update Date | 04/27/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 160 E NORTHPORT RD
-----------------------------------------------------
City | KINGS PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11754-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-269-6060
-----------------------------------------------------
Fax | 631-269-7173
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 160 E NORTHPORT RD
-----------------------------------------------------
City | KINGS PARK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11754-2541
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-269-6060
-----------------------------------------------------
Fax | 631-269-7173
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | GAIL F. GAROFALO
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 516-457-8552
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | N005196
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------