Provider Demographics
NPI:1285743161
Name:MERMELSTEIN, JOSEPH R (MD)
Entity type:Individual
Prefix:
First Name:JOSEPH
Middle Name:R
Last Name:MERMELSTEIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2177 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6603
Mailing Address - Country:US
Mailing Address - Phone:718-494-9055
Mailing Address - Fax:718-494-3713
Practice Address - Street 1:2177 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6603
Practice Address - Country:US
Practice Address - Phone:718-494-9055
Practice Address - Fax:718-494-3713
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162191207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00942750Medicaid
NY00942750Medicaid
NY47D501Medicare ID - Type Unspecified