Provider Demographics
NPI:1366514911
Name:ALLEN, EUSTACE
Entity type:Individual
Prefix:
First Name:EUSTACE
Middle Name:
Last Name:ALLEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 GRAND CONCOURSE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-1247
Mailing Address - Country:US
Mailing Address - Phone:718-365-6363
Mailing Address - Fax:
Practice Address - Street 1:1160 EASTERN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11213-6152
Practice Address - Country:US
Practice Address - Phone:718-756-1309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2016-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004866174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01345058Medicaid
NY01345058Medicaid
NYP54011Medicare PIN