Provider Demographics
NPI:1285660266
Name:EISENSTADT, AUDREY L (MD)
Entity Type:Individual
Prefix:DR
First Name:AUDREY
Middle Name:L
Last Name:EISENSTADT
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 1:369 E MAIN ST
Mailing Address - Street 2:SUITE 18
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2800
Mailing Address - Country:US
Mailing Address - Phone:631-277-1600
Mailing Address - Fax:631-277-1638
Practice Address - Street 1:369 E MAIN ST
Practice Address - Street 2:SUITE 18
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2800
Practice Address - Country:US
Practice Address - Phone:631-277-1600
Practice Address - Fax:631-277-1638
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2009-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1505942085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00893141Medicaid
NYA63595Medicare UPIN
NY64D731Medicare PIN