Organization
MONROE PODIATRY GROUP
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MR. RAYMOND DIVASTO DPM (OWNER)
(585) 872-6520
Entity
Organization
Contact information
Practice address
45 NORTH AVE, WEBSTER, NY 14580-3054
(585) 872-6520
(585) 872-6357
Mailing address
45 NORTH AVE, WEBSTER, NY 14580-3054
(585) 872-6520
(585) 872-6357
Taxonomy
Speciality
Code
Description
License number
State
213ES0131X
Foot Surgery Podiatrist
—
NY
332B00000X
Durable Medical Equipment & Medical Supplies
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
G0188302590
EXCELLUS BLUECROSS
NY
Enumeration date
11/13/2006
Last updated
07/21/2022
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