Healthcare Provider Details

I. General information

NPI: 1447367537
Provider Name (Legal Business Name): MITCHELL KLEINBERG M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2006
Last Update Date: 04/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

270 UNION AVE
HOLBROOK NY
11741-1823
US

IV. Provider business mailing address

270 UNION AVE
HOLBROOK NY
11741-1823
US

V. Phone/Fax

Practice location:
  • Phone: 631-558-4442
  • Fax: 631-471-3039
Mailing address:
  • Phone: 631-588-4442
  • Fax: 631-471-3039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number154133
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier00765857
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: