Provider Demographics
NPI:1184668808
Name:FAGELMAN, ELLIOT (MD)
Entity Type:Individual
Prefix:DR
First Name:ELLIOT
Middle Name:
Last Name:FAGELMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:ELLIOT
Other - Middle Name:
Other - Last Name:FAGELMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:11 MEDICAL PARK DR
Mailing Address - Street 2:SUITE 101
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3559
Mailing Address - Country:US
Mailing Address - Phone:845-354-5800
Mailing Address - Fax:845-354-5966
Practice Address - Street 1:11 MEDICAL PARK DR
Practice Address - Street 2:SUITE 101
Practice Address - City:POMONA
Practice Address - State:NY
Practice Address - Zip Code:10970-3559
Practice Address - Country:US
Practice Address - Phone:845-354-5800
Practice Address - Fax:845-354-5966
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY218046208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02154667Medicaid
NY02154667Medicaid
NY1S8781Medicare ID - Type Unspecified