Healthcare Provider Details

I. General information

NPI: 1255533311
Provider Name (Legal Business Name): ANTONIA P EYSSALLENNE MD, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/01/2007
Last Update Date: 05/29/2025
Certification Date: 05/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14015 SANFORD AVE STE B
FLUSHING NY
11355-2688
US

IV. Provider business mailing address

427 SAINT JOSEPH PL
FRANKLIN SQUARE NY
11010-2023
US

V. Phone/Fax

Practice location:
  • Phone: 718-450-9242
  • Fax:
Mailing address:
  • Phone: 305-298-8156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number301300
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: