Provider Demographics
NPI:1225029861
Name:DICKMAN, EITAN (MD)
Entity Type:Individual
Prefix:DR
First Name:EITAN
Middle Name:
Last Name:DICKMAN
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:PO BOX 29580
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10087-9580
Mailing Address - Country:US
Mailing Address - Phone:718-283-6057
Mailing Address - Fax:718-283-8713
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:718-283-6057
Practice Address - Fax:718-283-8713
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2009-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223623207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02593406Medicaid
NY8AR151Medicare PIN