Provider Demographics
NPI:1861567000
Name:MADISON AVENUE FOOTCARE, PC
Entity type:Organization
Organization Name:MADISON AVENUE FOOTCARE, PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NADYA
Authorized Official - Middle Name:E
Authorized Official - Last Name:DIMITROV
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:212-689-0206
Mailing Address - Street 1:350 OLD WILLETS PATH
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4120
Mailing Address - Country:US
Mailing Address - Phone:212-689-0206
Mailing Address - Fax:631-724-3252
Practice Address - Street 1:10 UNION SQ E
Practice Address - Street 2:2N
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003-3314
Practice Address - Country:US
Practice Address - Phone:212-844-8211
Practice Address - Fax:212-844-8201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-22
Last Update Date:2010-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004243213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01100283Medicaid
NYT51481Medicare UPIN
NY4872400001Medicare NSC
NY01100283Medicaid