Basic Information
| Provider Information | |||||||||
| NPI: | 1720078413 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GITLITZ | ||||||||
| FirstName: | ELLIOT | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 55 WATER ST | ||||||||
| Address2: | 2ND FLOOR CRED DEPT | ||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100410004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6466802888 | ||||||||
| FaxNumber: | 5165425556 | ||||||||
| Practice Location | |||||||||
| Address1: | 3175 23RD ST | ||||||||
| Address2: | |||||||||
| City: | ASTORIA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 111064134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189562200 | ||||||||
| FaxNumber: | 7189562316 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/25/2005 | ||||||||
| LastUpdateDate: | 09/12/2019 | ||||||||
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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 | N003465 | NY | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | P39163 | 01 | NY | EMPIRE BLUE CROSS/BLUE SH | OTHER | 00821958 | 05 | NY | MEDICAID | 57006A | 01 | NY | GHI PROVIDER ID | OTHER |