Healthcare Provider Details

I. General information

NPI: 1235185778
Provider Name (Legal Business Name): ALEXANDER EUGENE ISTOMIN MD MD, MS, MS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2006
Last Update Date: 07/06/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8708 JUSTICE AVE SUITE 2E
ELMHURST NY
11373-4575
US

IV. Provider business mailing address

PO BOX 95
OLD WESTBURY NY
11568-0095
US

V. Phone/Fax

Practice location:
  • Phone: 718-554-7434
  • Fax: 718-554-1666
Mailing address:
  • Phone: 718-554-7434
  • Fax: 718-554-1666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberARNP 9238727
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF304254
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number242862
License Number StateZZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: