Provider Demographics
NPI:1285680751
Name:MICKENBERG, IRA D (MD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:D
Last Name:MICKENBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:22 OLD WATERBURY RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:SOUTHBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06488-3848
Mailing Address - Country:US
Mailing Address - Phone:203-264-6503
Mailing Address - Fax:203-262-1430
Practice Address - Street 1:22 OLD WATERBURY RD
Practice Address - Street 2:SUITE 201
Practice Address - City:SOUTHBURY
Practice Address - State:CT
Practice Address - Zip Code:06488-3848
Practice Address - Country:US
Practice Address - Phone:203-264-6503
Practice Address - Fax:203-262-1430
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-26
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CT014557207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTB83695Medicare UPIN