Provider Demographics
NPI:1124013990
Name:NEYSTAT, MARINA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARINA
Middle Name:
Last Name:NEYSTAT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10124 QUEENS BLVD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-2703
Mailing Address - Country:US
Mailing Address - Phone:718-261-8881
Mailing Address - Fax:
Practice Address - Street 1:10124 QUEENS BLVD
Practice Address - Street 2:SUITE A
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-2703
Practice Address - Country:US
Practice Address - Phone:718-261-8881
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-16
Last Update Date:2012-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY200915-12084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY200915OtherNYS LICENSE
NY01724698Medicaid
NY200915OtherNYS LICENSE
NYG40100Medicare UPIN