Provider Demographics
NPI:1013956820
Name:COUCH, MICHAEL ANTHONY JR (DPM)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:COUCH
Suffix:JR
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4011 ARROWHEAD LN
Mailing Address - Street 2:
Mailing Address - City:LIVERPOOL
Mailing Address - State:NY
Mailing Address - Zip Code:13090-2821
Mailing Address - Country:US
Mailing Address - Phone:315-839-5575
Mailing Address - Fax:315-839-5587
Practice Address - Street 1:4011 ARROWHEAD LN
Practice Address - Street 2:
Practice Address - City:LIVERPOOL
Practice Address - State:NY
Practice Address - Zip Code:13090-2821
Practice Address - Country:US
Practice Address - Phone:315-409-4165
Practice Address - Fax:315-409-4165
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN005821-1213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02165644Medicaid
RA7400Medicare ID - Type Unspecified
NY02165644Medicaid