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General NPI Number Information
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NPI Number | 1932371374
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Entity Type | Organization
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Legal Business Name | SPA PODIATRY, PC
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Dates
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Enumeration Date | 03/26/2008
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Last Update Date | 05/18/2013
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Provider Practice Location Address
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Address Line | 3 HEMPHILL PL STE 111
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City | MALTA
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State | NY
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Zip | 12020-4420
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Country | US
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Telephone | 518-899-3338
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Fax |
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Provider Business Mailing Address
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Address Line | 3 HEMPHILL PL STE 111
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City | MALTA
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State | NY
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Zip | 12020-4420
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Country | US
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Telephone | 518-899-3338
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Fax | 518-899-5025
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Authorized Official
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Title or Position | SECRETARY/PARTNER
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Name | DR. RUSSELL JOSEPH MONGIOVI
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Credential | DPM
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Telephone | 518-899-3338
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | N004782
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License Number State | NY
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