Healthcare Provider Details

I. General information

NPI: 1770960270
Provider Name (Legal Business Name): ANDREW RUSSO KIBERT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2015
Last Update Date: 06/23/2026
Certification Date: 06/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

426 W 14TH ST FL 3
NEW YORK NY
10014-1002
US

IV. Provider business mailing address

426 W 14TH ST FL 3
NEW YORK NY
10014-1002
US

V. Phone/Fax

Practice location:
  • Phone: 646-568-6636
  • Fax:
Mailing address:
  • Phone: 646-568-6636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number285045
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: