Healthcare Provider Details

I. General information

NPI: 1386202158
Provider Name (Legal Business Name): NIKOLAI KLEBANOV MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2019
Last Update Date: 06/17/2024
Certification Date: 06/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 CUMMINGS CTR STE 311T
BEVERLY MA
01915-6260
US

IV. Provider business mailing address

680 CENTRE ST
BROCKTON MA
02302-3308
US

V. Phone/Fax

Practice location:
  • Phone: 978-225-3376
  • Fax: 978-560-1245
Mailing address:
  • Phone: 508-941-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number1014901
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: