Provider Demographics
NPI:1033119094
Name:WEINBERG, KENNETH (MD)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:WEINBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:476 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013-2641
Mailing Address - Country:US
Mailing Address - Phone:212-431-3395
Mailing Address - Fax:212-965-8892
Practice Address - Street 1:718 TEANECK RD
Practice Address - Street 2:
Practice Address - City:TEANECK
Practice Address - State:NJ
Practice Address - Zip Code:07666-4245
Practice Address - Country:US
Practice Address - Phone:201-833-3913
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-29
Last Update Date:2008-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04897900207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1997602Medicaid
NJ1997602Medicaid
E55053Medicare UPIN