=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811020571
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES W MISTRETTA, DPM, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/13/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23 IVY ST
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14701-8212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-664-9698
-----------------------------------------------------
Fax | 716-661-3851
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23 IVY ST
-----------------------------------------------------
City | JAMESTOWN
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 14701-8212
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 716-664-9698
-----------------------------------------------------
Fax | 716-661-3851
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. CHARLES W MISTRETTA
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 716-664-9698
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0131X
-----------------------------------------------------
Taxonomy Name | Foot Surgery Podiatrist
-----------------------------------------------------
License Number | N004011-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------