Provider Demographics
NPI:1144395112
Name:WOHLBERG, GARY (MD)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:WOHLBERG
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 1:370 EAST MAIN STREET
Mailing Address - Street 2:SUITE 5
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706
Mailing Address - Country:US
Mailing Address - Phone:631-666-5864
Mailing Address - Fax:631-666-1187
Practice Address - Street 1:370 EAST MAIN STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706
Practice Address - Country:US
Practice Address - Phone:631-666-5864
Practice Address - Fax:631-666-1187
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151718207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00986778Medicaid
NY00986778Medicaid
C12099Medicare UPIN