Provider Demographics
NPI:1235230004
Name:WANERMAN, JEFFREY B (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:B
Last Name:WANERMAN
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 1:333 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2719
Mailing Address - Country:US
Mailing Address - Phone:631-789-3999
Mailing Address - Fax:631-789-0809
Practice Address - Street 1:333 BROADWAY
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2719
Practice Address - Country:US
Practice Address - Phone:631-789-3999
Practice Address - Fax:631-789-0809
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164953207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01384207Medicaid
NYW02451Medicare ID - Type UnspecifiedGROUP MEDICARE NUMBER
NY01384207Medicaid