Healthcare Provider Details

I. General information

NPI: 1760476220
Provider Name (Legal Business Name): IRA BIRNBAUM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 SEAVIEW AVE
STATEN ISLAND NY
10305-3436
US

IV. Provider business mailing address

3 MAYFAIR CT
EAST BRUNSWICK NJ
08816-3508
US

V. Phone/Fax

Practice location:
  • Phone: 917-949-5833
  • Fax:
Mailing address:
  • Phone: 732-651-7224
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number190752
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RA0401X
TaxonomyAddiction Medicine (Internal Medicine) Physician
License Number190752
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: