=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780895888
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MIDDLE VILLAGE PODIATRY, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/24/2007
-----------------------------------------------------
Last Update Date | 11/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6412 FRESH POND RD
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11385-3331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-497-3000
-----------------------------------------------------
Fax | 718-497-3335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6412 FRESH POND RD
-----------------------------------------------------
City | RIDGEWOOD
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11385-3331
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 718-497-3000
-----------------------------------------------------
Fax | 718-497-3335
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. KAREN M AGLIETTI
-----------------------------------------------------
Credential | D.P.M.
-----------------------------------------------------
Telephone | 718-497-3000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213E00000X
-----------------------------------------------------
Taxonomy Name | Podiatrist
-----------------------------------------------------
License Number | N005171
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------