Provider Demographics
NPI:1588695712
Name:GELLERSTEIN, ALAN S (MD)
Entity type:Individual
Prefix:
First Name:ALAN
Middle Name:S
Last Name:GELLERSTEIN
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:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 SADDLE RD
Practice Address - Street 2:
Practice Address - City:CEDAR KNOLLS
Practice Address - State:NJ
Practice Address - Zip Code:07927-1901
Practice Address - Country:US
Practice Address - Phone:973-267-2122
Practice Address - Fax:973-292-1466
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06879300207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8326509Medicaid
027657B60Medicare ID - Type Unspecified
NJ8326509Medicaid