Provider Demographics
NPI:1548604788
Name:THEODORE KASTNER MD, PC
Entity Type:Organization
Organization Name:THEODORE KASTNER MD, PC
Other - Org Name:DEVELOPMENTAL DISABILITES HEALTH ALLIANCE NY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:THEODORE
Authorized Official - Middle Name:A
Authorized Official - Last Name:KASTNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-430-0038
Mailing Address - Street 1:1285 BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-3045
Mailing Address - Country:US
Mailing Address - Phone:718-430-0038
Mailing Address - Fax:973-338-4440
Practice Address - Street 1:1410 PELHAM PKWY S
Practice Address - Street 2:CHILDRENS EVALUATION AND REHABILITATION CENTER
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1116
Practice Address - Country:US
Practice Address - Phone:718-430-0038
Practice Address - Fax:973-338-4440
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-18
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154132-12080P0006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2080P0006XAllopathic & Osteopathic PhysiciansPediatricsDevelopmental - Behavioral PediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03731202Medicaid
NY03731202Medicaid