Provider Demographics
NPI:1346485745
Name:MEDAN, ITZHAK (MD)
Entity Type:Individual
Prefix:MR
First Name:ITZHAK
Middle Name:
Last Name:MEDAN
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 1:505 NOSTRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11216-2015
Mailing Address - Country:US
Mailing Address - Phone:718-622-4444
Mailing Address - Fax:
Practice Address - Street 1:151 CAROL LN
Practice Address - Street 2:
Practice Address - City:RICHBORO
Practice Address - State:PA
Practice Address - Zip Code:18954-1307
Practice Address - Country:US
Practice Address - Phone:443-676-2585
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-13
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231274-1208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice