Provider Demographics
NPI:1649377524
Name:BLYZNAK, NESTOR D (MD)
Entity type:Individual
Prefix:
First Name:NESTOR
Middle Name:D
Last Name:BLYZNAK
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 1:100 NICOLLS RD
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11794-8181
Mailing Address - Country:US
Mailing Address - Phone:631-444-6996
Mailing Address - Fax:631-444-7671
Practice Address - Street 1:100 NICOLLS RD
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8181
Practice Address - Country:US
Practice Address - Phone:631-444-6996
Practice Address - Fax:631-444-7671
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2012-10-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY150695207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY001077352Medicaid
NY26E191Medicare PIN
NYA61675Medicare UPIN