MEDICARE: DR. MARINA NEYSTAT M.D.

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	2084N0400X	Neurology Physician	200915-1	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	200915	OTHER	NY	NYS LICENSE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1124013990
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARINA NEYSTAT M.D.

Provider Business Mailing Address
First Line	:	10124 QUEENS BLVD
Second Line	:	SUITE A
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-2703
Country	:	US
Telephone Number	:	718-261-8881
Fax Number	:

Provider Business Practice Location Address
First Line	:	10124 QUEENS BLVD
Second Line	:	SUITE A
City	:	FOREST HILLS
State	:	NY
Zip	:	11375-2703
Country	:	US
Telephone Number	:	718-261-8881
Fax Number	:

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

Provider Enumeration Date	:	09/16/2005
Last Update Date	:	06/22/2012

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