Healthcare Provider Details

I. General information

NPI: 1336164292
Provider Name (Legal Business Name): KIMBERLY STONE HALTIWANGER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/13/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

646 COMMACK RD
COMMACK NY
11725-5404
US

IV. Provider business mailing address

646 COMMACK RD
COMMACK NY
11725-5404
US

V. Phone/Fax

Practice location:
  • Phone: 631-499-4114
  • Fax: 631-499-1468
Mailing address:
  • Phone: 631-499-4114
  • Fax: 631-499-1468

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number188281
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01821338
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 2
Identifier00401381
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: