Provider Demographics
NPI:1972841880
Name:MUSTALISH, ELAYNE K (MD)
Entity Type:Individual
Prefix:
First Name:ELAYNE
Middle Name:K
Last Name:MUSTALISH
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 1:170 E 83RD ST
Mailing Address - Street 2:APT. 4J
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-1920
Mailing Address - Country:US
Mailing Address - Phone:212-861-1715
Mailing Address - Fax:212-861-0293
Practice Address - Street 1:170 E 83RD ST
Practice Address - Street 2:APT. 4J
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-1920
Practice Address - Country:US
Practice Address - Phone:212-861-1715
Practice Address - Fax:212-861-0293
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-28
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY099581208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF51759Medicare UPIN