Healthcare Provider Details

I. General information

NPI: 1699313734
Provider Name (Legal Business Name): JEREMY MARK BIENENFELD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2019
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E 233RD ST
BRONX NY
10466-2604
US

IV. Provider business mailing address

1991 MARCUS AVE STE M200
NEW HYDE PARK NY
11042-3000
US

V. Phone/Fax

Practice location:
  • Phone: 718-920-9177
  • Fax:
Mailing address:
  • Phone: 516-204-4242
  • Fax: 347-236-3163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number027189
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: