Healthcare Provider Details

I. General information

NPI: 1003058868
Provider Name (Legal Business Name): BARRY PRYSTOWSKY, MD LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/25/2009
Last Update Date: 05/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

562 KINGSLAND ST
NUTLEY NJ
07110-1069
US

IV. Provider business mailing address

562 KINGSLAND ST
NUTLEY NJ
07110-1069
US

V. Phone/Fax

Practice location:
  • Phone: 973-235-0101
  • Fax:
Mailing address:
  • Phone: 973-235-0101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMA042255
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2061902
Identifier TypeMEDICAID
Identifier StateNJ
Identifier Issuer

VIII. Authorized Official

Name: DR. BARRY PRYSTOWSKY
Title or Position: OWNER
Credential: M.D.
Phone: 973-235-0101