MEDICARE: ENID GORIS DPM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	213ES0131X	Foot Surgery Podiatrist	N005792	NY
2	213EP1101X	Primary Podiatric Medicine Podiatrist	N005792	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PG 4272	OTHER	NY	PROVIDER ID #

General Provider Information

NPI Number	:	1588631816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ENID GORIS DPM

Provider Business Mailing Address
First Line	:	1827 EDISON AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-4101
Country	:	US
Telephone Number	:	718-863-7832
Fax Number	:	718-239-9989

Provider Business Practice Location Address
First Line	:	1827 EDISON AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10461-4101
Country	:	US
Telephone Number	:	718-863-7832
Fax Number	:	718-239-9989

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/06/2006
Last Update Date	:	12/14/2015

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Directions to “ ENID GORIS DPM” Practice Location

Language	Start Address	Practice Location

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