Provider Demographics
NPI:1972580926
Name:NUSSBAUM, MYRNA K (MD)
Entity Type:Individual
Prefix:DR
First Name:MYRNA
Middle Name:K
Last Name:NUSSBAUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:545 ELMONT RD
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-4002
Mailing Address - Country:US
Mailing Address - Phone:516-354-4200
Mailing Address - Fax:516-775-1972
Practice Address - Street 1:227 FRANKLIN AVE
Practice Address - Street 2:
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1902
Practice Address - Country:US
Practice Address - Phone:516-295-5500
Practice Address - Fax:516-569-8225
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1571042085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01967477Medicaid
NY01967477Medicaid
NY29F411Medicare PIN
NYE68909Medicare UPIN
NY29F4198391Medicare PIN
NY29F4113091Medicare PIN