Provider Demographics
NPI:1073549358
Name:BIRNBAUM, ALLAN JAY (DO)
Entity Type:Individual
Prefix:DR
First Name:ALLAN
Middle Name:JAY
Last Name:BIRNBAUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1701 SE HILLMOOR DR
Mailing Address - Street 2:SUITE #5
Mailing Address - City:PORT SAINT LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34952-7552
Mailing Address - Country:US
Mailing Address - Phone:772-485-7507
Mailing Address - Fax:772-398-9505
Practice Address - Street 1:1701 SE HILLMOOR DR
Practice Address - Street 2:SUITE #5
Practice Address - City:PORT SAINT LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34952-7552
Practice Address - Country:US
Practice Address - Phone:772-485-7507
Practice Address - Fax:772-398-9505
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS4258207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E32252Medicare UPIN
82505Medicare ID - Type Unspecified