Provider Demographics
NPI:1508804311
Name:BERNSTEIN, EVAN KEITH (DC)
Entity Type:Individual
Prefix:
First Name:EVAN
Middle Name:KEITH
Last Name:BERNSTEIN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2780 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 140
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-2124
Mailing Address - Country:US
Mailing Address - Phone:631-580-1000
Mailing Address - Fax:631-580-0483
Practice Address - Street 1:2780 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 140
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-2124
Practice Address - Country:US
Practice Address - Phone:631-580-1000
Practice Address - Fax:631-580-0483
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX007674111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU68184Medicare UPIN