Provider Demographics
NPI:1699776674
Name:KORMYLO, DANIEL (DPM)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:KORMYLO
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:PO BOX 5153
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-0969
Mailing Address - Country:US
Mailing Address - Phone:631-744-8282
Mailing Address - Fax:631-821-5583
Practice Address - Street 1:745 RT 25A
Practice Address - Street 2:SUITE B
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-0969
Practice Address - Country:US
Practice Address - Phone:631-744-8282
Practice Address - Fax:631-821-5583
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-02
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004250213E00000X
NY004250213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01070722Medicaid
480008364OtherMEDICARE RAILROAD
NY1049990002OtherMEDICARE DME
NY1049990002OtherMEDICARE DME