Provider Demographics
NPI:1770567166
Name:JAY MERMELSTEIN DPM PC
Entity type:Organization
Organization Name:JAY MERMELSTEIN DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAY
Authorized Official - Middle Name:
Authorized Official - Last Name:MERMELSTEIN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:914-699-1515
Mailing Address - Street 1:105 STEVENS AVE
Mailing Address - Street 2:STE 301
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-2686
Mailing Address - Country:US
Mailing Address - Phone:914-699-1515
Mailing Address - Fax:914-699-2907
Practice Address - Street 1:105 STEVENS AVE
Practice Address - Street 2:STE 301
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2686
Practice Address - Country:US
Practice Address - Phone:914-699-1515
Practice Address - Fax:914-699-2907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-30
Last Update Date:2007-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004414213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01084459Medicaid
PBWFO1Medicare PIN
T51477Medicare UPIN
NY5699250001Medicare NSC