Provider Demographics
NPI:1821142464
Name:TENNENBAUM, ERIC PAUL (OD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:PAUL
Last Name:TENNENBAUM
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 LAUX PL
Mailing Address - Street 2:
Mailing Address - City:NORTH BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-2027
Mailing Address - Country:US
Mailing Address - Phone:516-221-1457
Mailing Address - Fax:
Practice Address - Street 1:1050A SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:MASSAPEQUA
Practice Address - State:NY
Practice Address - Zip Code:11758-5325
Practice Address - Country:US
Practice Address - Phone:516-795-7610
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV 4951152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYC45091Medicare ID - Type Unspecified
NYUO5636Medicare UPIN