Healthcare Provider Details

I. General information

NPI: 1023227659
Provider Name (Legal Business Name): ANDREW ELLISTON M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

82 NASSAU ST STE 60518
NEW YORK NY
10038-3703
US

IV. Provider business mailing address

82 NASSAU ST STE 60518
NEW YORK NY
10038-3703
US

V. Phone/Fax

Practice location:
  • Phone: 917-746-2455
  • Fax: 917-746-9649
Mailing address:
  • Phone: 917-746-2455
  • Fax: 917-746-9649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number274229
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: