Provider Demographics
NPI:1164575379
Name:EBENSTEIN, PETER (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:EBENSTEIN
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 1:12 GREENRIDGE AVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-1238
Mailing Address - Country:US
Mailing Address - Phone:914-287-0010
Mailing Address - Fax:914-287-0952
Practice Address - Street 1:12 GREENRIDGE AVE
Practice Address - Street 2:SUITE 204
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10605-1238
Practice Address - Country:US
Practice Address - Phone:914-287-0010
Practice Address - Fax:914-287-0952
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY131759207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01014722Medicaid
NY80D611Medicare ID - Type UnspecifiedBLUE SHIELD- MEDICARE #
NY01014722Medicaid