=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659766681
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SEBASTIAN SHTERENTAL MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/06/2015
-----------------------------------------------------
Last Update Date | 07/28/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 733 SUNRISE HWY FL 2
-----------------------------------------------------
City | LYNBROOK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11563-2910
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-927-1500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11358 MEADOW FLOWER PL
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92127-2035
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 304976
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------