Provider Demographics
NPI:1063272474
Name:EASTBAY MEDICAL PC
Entity type:Organization
Organization Name:EASTBAY MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DO
Authorized Official - Prefix:
Authorized Official - First Name:JORDAN
Authorized Official - Middle Name:
Authorized Official - Last Name:FABRIKANT
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:516-308-7070
Mailing Address - Street 1:2307 BELLMORE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLMORE
Mailing Address - State:NY
Mailing Address - Zip Code:11710-5651
Mailing Address - Country:US
Mailing Address - Phone:513-308-7070
Mailing Address - Fax:516-308-7071
Practice Address - Street 1:2307 BELLMORE AVE
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-5651
Practice Address - Country:US
Practice Address - Phone:516-308-7070
Practice Address - Fax:516-308-7071
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty