Provider Demographics
NPI:1265405500
Name:GEWIRTZ, ILENE (MD)
Entity type:Individual
Prefix:DR
First Name:ILENE
Middle Name:
Last Name:GEWIRTZ
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 1:369 E MAIN ST
Mailing Address - Street 2:SUITE11 BLDG 2
Mailing Address - City:EAST ISLIP
Mailing Address - State:NY
Mailing Address - Zip Code:11730-2800
Mailing Address - Country:US
Mailing Address - Phone:631-859-9793
Mailing Address - Fax:631-277-4608
Practice Address - Street 1:369 E MAIN ST
Practice Address - Street 2:SUITE11 BLDG 2
Practice Address - City:EAST ISLIP
Practice Address - State:NY
Practice Address - Zip Code:11730-2800
Practice Address - Country:US
Practice Address - Phone:631-859-9793
Practice Address - Fax:631-277-4608
Is Sole Proprietor?:No
Enumeration Date:2006-02-08
Last Update Date:2012-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163315207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB11383Medicare UPIN
NYIGO24E3910Medicare ID - Type Unspecified