Basic Information
Provider Information | |||||||||
NPI: | 1801866132 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LIPSZTEIN | ||||||||
FirstName: | ROBERTO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 106-14 70TH AVENUE | ||||||||
Address2: |   | ||||||||
City: | FOREST HILLS | ||||||||
State: | NY | ||||||||
PostalCode: | 11375 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7185206620 | ||||||||
FaxNumber: | 7185206630 | ||||||||
Practice Location | |||||||||
Address1: | 106-14 70TH AVENUE | ||||||||
Address2: |   | ||||||||
City: | FOREST HILLS | ||||||||
State: | NY | ||||||||
PostalCode: | 11375 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7185206620 | ||||||||
FaxNumber: | 7185206630 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/26/2006 | ||||||||
LastUpdateDate: | 04/19/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 143484 | NY | N |   | Other Service Providers | Specialist |   | 2085R0001X | 143484 | NY | Y |   | Allopathic & Osteopathic Physicians | Radiology | Radiation Oncology |
ID Information
ID | Type | State | Issuer | Description | 0063735 | 01 | NY | GHI | OTHER | 166050 | 01 | NY | ELDERPLAN | OTHER | 00794909 | 05 | NY |   | MEDICAID | 113089245 | 01 | NY | TAX ID | OTHER | NS757 | 01 | NY | OXFORD | OTHER | 0C5533 | 01 | NY | HEALTHNET | OTHER | 27091P | 01 | NY | HIP | OTHER |