Provider Demographics
NPI:1972938512
Name:GLENWOOD PODIATRY PC
Entity type:Organization
Organization Name:GLENWOOD PODIATRY PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:H
Authorized Official - Last Name:STARK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-821-2161
Mailing Address - Street 1:6216 MYRTLE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11385-6236
Mailing Address - Country:US
Mailing Address - Phone:718-821-2161
Mailing Address - Fax:718-821-1252
Practice Address - Street 1:6216 MYRTLE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:NY
Practice Address - Zip Code:11385-6236
Practice Address - Country:US
Practice Address - Phone:718-821-2161
Practice Address - Fax:718-821-1252
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-12
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004970213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP55121Medicare PIN
NY02423Medicare PIN