Provider Demographics
NPI:1063443257
Name:BLYSKAL, STANLEY (MD)
Entity Type:Individual
Prefix:
First Name:STANLEY
Middle Name:
Last Name:BLYSKAL
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 1:126 E MAIN ST
Mailing Address - Street 2:STE 1
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2600
Mailing Address - Country:US
Mailing Address - Phone:631-581-0090
Mailing Address - Fax:631-581-2879
Practice Address - Street 1:126 E MAIN ST
Practice Address - Street 2:STE 1
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2600
Practice Address - Country:US
Practice Address - Phone:631-581-0090
Practice Address - Fax:631-581-2879
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY124015207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00425489Medicaid
NY319351Medicare PIN
NYB12881Medicare UPIN