1447286638 NPI number — MARILYN S BOYUKA DPM

Table of content: MARILYN S BOYUKA DPM (NPI 1447286638)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1447286638 NPI number — MARILYN S BOYUKA DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BOYUKA
Provider First Name:
MARILYN
Provider Middle Name:
S
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1447286638
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/19/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4104 OLD VESTAL RD
Provider Second Line Business Mailing Address:
SUITE 104
Provider Business Mailing Address City Name:
VESTAL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
13850-3500
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
607-217-5289
Provider Business Mailing Address Fax Number:
607-821-0255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4104 OLD VESTAL RD
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
VESTAL
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
13850-3500
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
607-217-5289
Provider Business Practice Location Address Fax Number:
607-821-0255
Provider Enumeration Date:
06/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213ES0103X , with the licence number:  N006043 , 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: 1447286638 . This is a "GROUP MEMBER NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: P01326012 . This is a "RR MEDICARE GROUP MEMBER PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1831439660 . This is a "SOUTHERN TIER PODIATRY, GROUP NPI" identifier . This identifiers is of the category "OTHER".
  • Identifier: DU7701 . This is a "RR MEDICARE GROUP PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 67743610001 . This is a "MEDICARE, DME PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: J100088341 . This is a "SOUTHERN TIER PODIATRY, GROUP PTAN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 02594714 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: J400088344 . This is a "MEDICARE GROUP MEMBER PTAN" identifier . This identifiers is of the category "OTHER".




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