Provider Demographics
NPI:1386602027
Name:KINATUKARA, SHIBU (DPM)
Entity type:Individual
Prefix:DR
First Name:SHIBU
Middle Name:
Last Name:KINATUKARA
Suffix:
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 1:1977 RALPH AVE STE 418
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5416
Mailing Address - Country:US
Mailing Address - Phone:718-258-4100
Mailing Address - Fax:718-251-1122
Practice Address - Street 1:1640 OCEAN AVE
Practice Address - Street 2:SUITE 1B
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-4963
Practice Address - Country:US
Practice Address - Phone:718-258-4100
Practice Address - Fax:718-251-1856
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2024-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYNOO5595213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2287975OtherUNITED HEALTHCARE
NY6299162OtherGHI
NY4695OtherGHI MEDICARE
NY2205136Medicaid
NJ0051331Medicaid
NYP2743644OtherOXFORD
NY2205136Medicaid