Provider Demographics
NPI:1033108220
Name:GERSHBAUM, MEYER DAVID (MD)
Entity Type:Individual
Prefix:
First Name:MEYER
Middle Name:DAVID
Last Name:GERSHBAUM
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 1:365 WOODMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11598-2047
Mailing Address - Country:US
Mailing Address - Phone:516-812-8662
Mailing Address - Fax:
Practice Address - Street 1:5842 MAIN ST
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-5336
Practice Address - Country:US
Practice Address - Phone:718-353-3710
Practice Address - Fax:718-463-0400
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-19
Last Update Date:2012-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208375174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02520730Medicaid
NYH90488Medicare UPIN
NY02520730Medicaid