Provider Demographics
NPI:1417934555
Name:MARIENBERG, EVELYN S (MD)
Entity Type:Individual
Prefix:DR
First Name:EVELYN
Middle Name:S
Last Name:MARIENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:450 CLARKSON AVE
Mailing Address - Street 2:BOX 1262
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-2056
Mailing Address - Country:US
Mailing Address - Phone:718-270-8867
Mailing Address - Fax:718-270-1794
Practice Address - Street 1:450 CLARKSON AVE
Practice Address - Street 2:RM ALL1369
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2056
Practice Address - Country:US
Practice Address - Phone:718-270-1593
Practice Address - Fax:718-270-1535
Is Sole Proprietor?:No
Enumeration Date:2005-12-29
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY179321-12085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01458731Medicaid
NYF13029Medicare UPIN
NY74H811Medicare ID - Type Unspecified