Basic Information
| Provider Information | |||||||||
| NPI: | 1184712945 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WEINSTEIN | ||||||||
| FirstName: | GARY | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | VAYNSHTEYN | ||||||||
| OtherFirstName: | IGOR | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 79 THE DELL ST | ||||||||
| Address2: | |||||||||
| City: | ALBERTSON | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11507 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186611789 | ||||||||
| FaxNumber: | 7188300724 | ||||||||
| Practice Location | |||||||||
| Address1: | 107-21 QUEENS BLVD | ||||||||
| Address2: | STE 6 | ||||||||
| City: | FOREST HILLS | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11375 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7186611789 | ||||||||
| FaxNumber: | 7188300724 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 203846 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 01733802 | 05 | NY | MEDICAID |