Provider Demographics
NPI:1295701787
Name:ESOPUS MEDICAL, PC
Entity type:Organization
Organization Name:ESOPUS MEDICAL, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MONIKA
Authorized Official - Middle Name:RA
Authorized Official - Last Name:MOMMSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:845-658-7763
Mailing Address - Street 1:10 HELLBROOK LN
Mailing Address - Street 2:
Mailing Address - City:ULSTER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12487-5209
Mailing Address - Country:US
Mailing Address - Phone:845-658-7763
Mailing Address - Fax:
Practice Address - Street 1:105 WOODCREST DR
Practice Address - Street 2:
Practice Address - City:RIFTON
Practice Address - State:NY
Practice Address - Zip Code:12471-7200
Practice Address - Country:US
Practice Address - Phone:845-658-7763
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-24
Last Update Date:2022-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY52862207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02533053Medicaid
A100001016Medicare PIN