Provider Demographics
NPI:1528226065
Name:BYSTOCK, MARC D (LAC)
Entity Type:Individual
Prefix:
First Name:MARC
Middle Name:D
Last Name:BYSTOCK
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 5TH AVE
Mailing Address - Street 2:SUITE 121
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217-3227
Mailing Address - Country:US
Mailing Address - Phone:917-558-6450
Mailing Address - Fax:
Practice Address - Street 1:134 W 26TH ST
Practice Address - Street 2:SUITE 903
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10001-6803
Practice Address - Country:US
Practice Address - Phone:917-558-6450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-31
Last Update Date:2008-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001680-1171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist