Provider Demographics
NPI:1619221926
Name:RYAN D'AMICO DPM PLLC
Entity type:Organization
Organization Name:RYAN D'AMICO DPM PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:L
Authorized Official - Last Name:D'AMICO
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:315-446-3668
Mailing Address - Street 1:7075 MANLIUS CENTER RD
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-2607
Mailing Address - Country:US
Mailing Address - Phone:315-446-3668
Mailing Address - Fax:315-849-1182
Practice Address - Street 1:7075 MANLIUS CENTER RD
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-2607
Practice Address - Country:US
Practice Address - Phone:315-446-3668
Practice Address - Fax:315-849-1182
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-08
Last Update Date:2019-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006349213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03553528Medicaid
NYJ100083891Medicare PIN
NY6946750001Medicare NSC