Healthcare Provider Details

I. General information

NPI: 1972580926
Provider Name (Legal Business Name): MYRNA K. NUSSBAUM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

227 FRANKLIN AVE
HEWLETT NY
11557-1902
US

IV. Provider business mailing address

545 ELMONT RD
ELMONT NY
11003-4002
US

V. Phone/Fax

Practice location:
  • Phone: 516-295-5500
  • Fax: 516-569-8225
Mailing address:
  • Phone: 516-354-4200
  • Fax: 516-775-1972

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number157104
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: