Provider Demographics
NPI:1194786772
Name:BRUSHTEIN, ROMAN (MD)
Entity type:Individual
Prefix:
First Name:ROMAN
Middle Name:
Last Name:BRUSHTEIN
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 1:303 MERRICK RD
Mailing Address - Street 2:SUITE 511
Mailing Address - City:LYNBROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11563-2501
Mailing Address - Country:US
Mailing Address - Phone:516-596-3611
Mailing Address - Fax:516-596-3612
Practice Address - Street 1:303 MERRICK RD
Practice Address - Street 2:SUITE 511
Practice Address - City:LYNBROOK
Practice Address - State:NY
Practice Address - Zip Code:11563-2501
Practice Address - Country:US
Practice Address - Phone:516-596-3611
Practice Address - Fax:516-596-3612
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2010-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY233198207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02369253Medicaid
NY02369253Medicaid
H69375Medicare UPIN