Provider Demographics
NPI:1821209263
Name:WILLIAM FASTENBERG MD PC
Entity Type:Organization
Organization Name:WILLIAM FASTENBERG MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:
Authorized Official - Last Name:FASTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:917-838-5680
Mailing Address - Street 1:260 WEST BROADWAY
Mailing Address - Street 2:SUITE 6F
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561
Mailing Address - Country:US
Mailing Address - Phone:917-838-5680
Mailing Address - Fax:
Practice Address - Street 1:260 WEST BROADWAY
Practice Address - Street 2:SUITE 6F
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561
Practice Address - Country:US
Practice Address - Phone:917-838-5680
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-25
Last Update Date:2014-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083746207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00124983Medicaid
B11723Medicare UPIN
NY00124983Medicaid