Provider Demographics
NPI:1376818039
Name:FODERA, VITO (MD)
Entity type:Individual
Prefix:DR
First Name:VITO
Middle Name:
Last Name:FODERA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:763 LARKFIELD RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-3131
Mailing Address - Country:US
Mailing Address - Phone:631-489-5000
Mailing Address - Fax:631-858-1990
Practice Address - Street 1:763 LARKFIELD RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-3131
Practice Address - Country:US
Practice Address - Phone:631-489-5000
Practice Address - Fax:631-858-1990
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-14
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY602645562085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400090538Medicaid