Provider Demographics
NPI:1598056285
Name:DIENSTAG, PENINA YEHUDIT (MD)
Entity Type:Individual
Prefix:
First Name:PENINA
Middle Name:YEHUDIT
Last Name:DIENSTAG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PENINA
Other - Middle Name:YEHUDIT
Other - Last Name:EISENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11781 LEE JACKSON MEMORIAL HIGHWAY
Mailing Address - Street 2:ST 550
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22033
Mailing Address - Country:US
Mailing Address - Phone:571-777-5164
Mailing Address - Fax:703-890-2650
Practice Address - Street 1:1 HEALTHY WAY
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:NY
Practice Address - Zip Code:11572-1551
Practice Address - Country:US
Practice Address - Phone:877-768-8462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-28
Last Update Date:2015-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276586207L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology