Provider Demographics
NPI:1386756146
Name:POLISTINA, DEAN CARL (MD)
Entity type:Individual
Prefix:DR
First Name:DEAN
Middle Name:CARL
Last Name:POLISTINA
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 1:30 WEST 60TH ST
Mailing Address - Street 2:SUITE 1Y
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023
Mailing Address - Country:US
Mailing Address - Phone:212-262-5177
Mailing Address - Fax:212-265-8225
Practice Address - Street 1:30 WEST 60TH ST
Practice Address - Street 2:SUITE 1Y
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10023
Practice Address - Country:US
Practice Address - Phone:212-262-5177
Practice Address - Fax:212-265-8225
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY193200207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01636277Medicaid
G22953Medicare UPIN
NY01636277Medicaid