Provider Demographics
NPI:1164509246
Name:DERMATOLOGIC SURGERY AT CRYSTAL RUN
Entity Type:Organization
Organization Name:DERMATOLOGIC SURGERY AT CRYSTAL RUN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:YEHUDA
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:ELIEZRI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-692-3376
Mailing Address - Street 1:28 RYKOWSKI LN
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:NY
Mailing Address - Zip Code:10941-4018
Mailing Address - Country:US
Mailing Address - Phone:845-692-3376
Mailing Address - Fax:845-692-0124
Practice Address - Street 1:7A MEDICAL PARK DR
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3516
Practice Address - Country:US
Practice Address - Phone:845-354-1169
Practice Address - Fax:845-362-5126
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154268207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYWEG661Medicare ID - Type Unspecified