Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 122300000X | Dentist | 00055621 | NY |
N | 122300000X | Dentist | 22DI02480400 | NJ |
Y | 1223D0004X | Dentist Anesthesiologist | 00055621 | NY |
N | 1223D0004X | Dentist Anesthesiologist | 22DI02480400 | NJ |
NPI | 1881919728 |
---|---|
Provider Name | Jacob Eisdorfer |
First Address | Brooklyn, NY 11219-1213 |
Second Address | Brooklyn, NY 11219-1213 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 04/04/2010 |
Last Update Date | 24/03/2015 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
03355406 | (05) | NY |