Provider Demographics
NPI:1104190065
Name:DEAN C POLISTINA MD PLLC
Entity Type:Organization
Organization Name:DEAN C POLISTINA MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:POLISTINA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-957-6933
Mailing Address - Street 1:200 W 57TH ST
Mailing Address - Street 2:SUITE 1410
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3211
Mailing Address - Country:US
Mailing Address - Phone:212-957-6933
Mailing Address - Fax:212-957-3477
Practice Address - Street 1:200 W 57TH ST
Practice Address - Street 2:SUITE 1410
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-3211
Practice Address - Country:US
Practice Address - Phone:212-957-6933
Practice Address - Fax:212-957-3477
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-23
Last Update Date:2012-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193200207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5598510OtherAETNA
NYP535102OtherOXFORD
NY01636277Medicaid
NY06416OtherBC/BS
NYPRIS 31763POtherHIP
NYP535102OtherOXFORD
NY06416Medicare PIN