Provider Demographics
NPI:1922058585
Name:BIENENSTOCK, HOLLY (DO)
Entity Type:Individual
Prefix:DR
First Name:HOLLY
Middle Name:
Last Name:BIENENSTOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14 MAPLE ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-2946
Mailing Address - Country:US
Mailing Address - Phone:516-767-3161
Mailing Address - Fax:516-767-3143
Practice Address - Street 1:14 MAPLE ST
Practice Address - Street 2:SUITE 103
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-2946
Practice Address - Country:US
Practice Address - Phone:516-767-3161
Practice Address - Fax:516-767-3143
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1638491207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
12F411Medicare PIN
NYB10485Medicare UPIN