Provider Demographics
NPI:1386202158
Name:KLEBANOV, NIKOLAI (MD)
Entity Type:Individual
Prefix:DR
First Name:NIKOLAI
Middle Name:
Last Name:KLEBANOV
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 1:680 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3308
Mailing Address - Country:US
Mailing Address - Phone:508-941-7000
Mailing Address - Fax:
Practice Address - Street 1:41 MALL ROAD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01805-3308
Practice Address - Country:US
Practice Address - Phone:781-744-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA280386208D00000X
MA1014901207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice