Healthcare Provider Details

I. General information

NPI: 1184628604
Provider Name (Legal Business Name): STEPHEN ALLAN OBSTBAUM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2005
Last Update Date: 09/04/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 E 39TH ST
NEW YORK NY
10016-0943
US

IV. Provider business mailing address

210 E 64TH ST
NEW YORK NY
10065-7471
US

V. Phone/Fax

Practice location:
  • Phone: 212-687-4106
  • Fax: 212-983-6497
Mailing address:
  • Phone: 212-702-7300
  • Fax: 212-702-7678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number101642
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: