MEDICARE: ELI DYCKMAN OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist		NY

General Provider Information

NPI Number	:	1114393303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELI DYCKMAN OTR/L

Provider Business Mailing Address
First Line	:	2161 61ST ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-2570
Country	:	US
Telephone Number	:	347-243-2171
Fax Number	:

Provider Business Practice Location Address
First Line	:	2161 61ST ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-2570
Country	:	US
Telephone Number	:	347-243-2171
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/11/2015
Last Update Date	:	02/28/2025

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