MEDICARE: JB WYNBERG MD PC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208800000X	Urology Physician

General Provider Information

NPI Number	:	1407182389
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	JB WYNBERG MD PC

Provider Business Mailing Address
First Line	:	1853 61ST ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-2353
Country	:	US
Telephone Number	:	718-743-7090
Fax Number	:

Provider Business Practice Location Address
First Line	:	1853 61ST ST
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11204-2353
Country	:	US
Telephone Number	:	718-743-7090
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	JASON WYNBERG
Credential	:	MD
Telephone Number	:	718-743-7090

Provider Enumeration Date	:	10/27/2009
Last Update Date	:	10/30/2009

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