1346226909 NPI number — DR. MATTHEW KASSNOVE D.P.M.

Table of content: DR. MATTHEW KASSNOVE D.P.M. (NPI 1346226909)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1346226909 NPI number — DR. MATTHEW KASSNOVE D.P.M.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
KASSNOVE
Provider First Name:
MATTHEW
Provider Middle Name:
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.P.M.
Provider Gender Code:
M

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:
1346226909
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/08/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
28 DEEPDALE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COMMACK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11725-5506
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
631-462-0060
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
440 WAVERLY AVE STE 3
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
PATCHOGUE
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11772-1597
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-654-3838
Provider Business Practice Location Address Fax Number:
631-654-3832
Provider Enumeration Date:
12/15/2005

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: 213ES0131X , with the licence number:  N005591 , 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: 02354814-5 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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