1518078708 NPI number — MOHAWK VALLEY PODIATRY PC

Table of content: (NPI 1518078708)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518078708 NPI number — MOHAWK VALLEY PODIATRY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MOHAWK VALLEY PODIATRY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DR ROBERT C DICAPRIO, JR
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1518078708
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 427
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FULTONVILLE
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12072-0427
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-853-3999
Provider Business Mailing Address Fax Number:
518-374-1818

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FULTONVILLE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12072-0427
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-853-3999
Provider Business Practice Location Address Fax Number:
518-374-1818
Provider Enumeration Date:
08/31/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DICAPRIO
Authorized Official First Name:
ROBERT
Authorized Official Middle Name:
CARL
Authorized Official Title or Position:
OWNER/PRACTITIONER
Authorized Official Telephone Number:
518-853-3999

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  N004755 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 54134 . This is a "MVP" identifier . This identifiers is of the category "OTHER".
  • Identifier: P114421 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10000492 . This is a "CDPHP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 000448056003 . This is a "BLUE SHIELD" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 01554094 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".