Provider Demographics
NPI:1679619233
Name:DISLA, EDDYS (MD)
Entity type:Individual
Prefix:
First Name:EDDYS
Middle Name:
Last Name:DISLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95000-2433
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19195-0001
Mailing Address - Country:US
Mailing Address - Phone:212-420-3131
Mailing Address - Fax:
Practice Address - Street 1:1ST AVE & E 16TH ST
Practice Address - Street 2:7TH FLOOR
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-420-3131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY182472207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY27K021Medicare ID - Type UnspecifiedEMPIRE PROVIDER # 10003
NY27K022Medicare ID - Type UnspecifiedEMPIRE PROVIDER # 10033
NYF28292Medicare UPIN