Basic Information
| Provider Information | |||||||||
| NPI: | 1457334583 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GEORGE | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13876 QUEENS BLVD FL 1 | ||||||||
| Address2: | |||||||||
| City: | BRIARWOOD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 114352930 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188506345 | ||||||||
| FaxNumber: | 7185594895 | ||||||||
| Practice Location | |||||||||
| Address1: | 242 MASON AVE | ||||||||
| Address2: | |||||||||
| City: | STATEN ISLAND | ||||||||
| State: | NY | ||||||||
| PostalCode: | 103053408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182266340 | ||||||||
| FaxNumber: | 7182266178 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/22/2005 | ||||||||
| LastUpdateDate: | 12/23/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 005780 | NY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 510429841 | 01 | NY | TAX ID# | OTHER | 02176718 | 05 | NY | MEDICAID |