Provider Demographics
NPI:1366480675
Name:ELLSTEIN, JERRY (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:ELLSTEIN
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 92
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-0092
Mailing Address - Country:US
Mailing Address - Phone:631-427-4263
Mailing Address - Fax:631-427-4279
Practice Address - Street 1:166 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2948
Practice Address - Country:US
Practice Address - Phone:631-427-4263
Practice Address - Fax:631-427-4279
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2012-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY136138207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY136138OtherLICENSE
A61218Medicare UPIN
NY136138OtherLICENSE