Basic Information
| Provider Information | |||||||||
| NPI: | 1497759336 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CORTESE | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 48 TUNNEL RD | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179013875 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706220473 | ||||||||
| FaxNumber: | 5706244116 | ||||||||
| Practice Location | |||||||||
| Address1: | 1626 MOUNT HOPE AVE | ||||||||
| Address2: | |||||||||
| City: | POTTSVILLE | ||||||||
| State: | PA | ||||||||
| PostalCode: | 179011302 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5706222230 | ||||||||
| FaxNumber: | 5706225724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/09/2005 | ||||||||
| LastUpdateDate: | 11/20/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213EP1101X | SC002264L | PA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist | Primary Podiatric Medicine |
ID Information
| ID | Type | State | Issuer | Description | 0012668300003 | 05 | PA | MEDICAID |