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General NPI Number Information
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NPI Number | 1912777954
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Entity Type | Organization
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Legal Business Name | OPTIMUM PODIATRY GROUP PLLC
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Dates
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Enumeration Date | 01/02/2024
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Last Update Date | 01/02/2024
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Provider Practice Location Address
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Address Line | 620 SUFFOLK AVE
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City | BRENTWOOD
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State | NY
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Zip | 11717-4306
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Country | US
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Telephone | 631-968-5600
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Fax |
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Provider Business Mailing Address
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Address Line | 620 SUFFOLK AVE
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City | BRENTWOOD
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State | NY
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Zip | 11717-4306
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | PETER MANCUSO
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Credential | DPM
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Telephone | 631-968-5600
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number |
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License Number State |
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