Provider Demographics
NPI:1164478871
Name:EISDORFER, MIRIAM (PSYD)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:EISDORFER
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 59TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-5016
Mailing Address - Country:US
Mailing Address - Phone:718-851-6254
Mailing Address - Fax:
Practice Address - Street 1:18 MIDDLETON ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11206-5415
Practice Address - Country:US
Practice Address - Phone:718-875-6900
Practice Address - Fax:718-875-3282
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY012869103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00012869Medicaid
NYW14871Medicare ID - Type Unspecified
NY00012869Medicaid