Provider Demographics
NPI:1073735593
Name:FASTENBERG, MICHAEL (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:FASTENBERG
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 1:260 MIDDLE COUNTRY RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2982
Mailing Address - Country:US
Mailing Address - Phone:631-863-3223
Mailing Address - Fax:631-863-3334
Practice Address - Street 1:260 MIDDLE COUNTRY RD
Practice Address - Street 2:SUITE 208
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2982
Practice Address - Country:US
Practice Address - Phone:631-863-3223
Practice Address - Fax:631-863-3334
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2011-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-01943207N00000X
NY252150-1207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A400015252Medicare PIN