Provider Demographics
NPI:1447337738
Name:GENOVESE, MARIO NICHOLAS (DPM)
Entity type:Individual
Prefix:DR
First Name:MARIO
Middle Name:NICHOLAS
Last Name:GENOVESE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7715 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-3439
Mailing Address - Country:US
Mailing Address - Phone:718-748-7474
Mailing Address - Fax:718-667-0782
Practice Address - Street 1:7715 4TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-3439
Practice Address - Country:US
Practice Address - Phone:718-748-7474
Practice Address - Fax:718-667-0782
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004091213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY11-3504574OtherTAX IDENTIFICATION NUMBER
NY01008846Medicaid
P44033Medicare PIN
NYT81565Medicare UPIN
P44032Medicare PIN