Provider Demographics
NPI:1417936469
Name:NUDELMAN, JEFFREY S (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:S
Last Name:NUDELMAN
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 1:500 W MAIN ST
Mailing Address - Street 2:SUITE 210
Mailing Address - City:BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11702-3027
Mailing Address - Country:US
Mailing Address - Phone:631-957-3355
Mailing Address - Fax:631-957-4378
Practice Address - Street 1:500 W MAIN ST
Practice Address - Street 2:#210
Practice Address - City:BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11702-3027
Practice Address - Country:US
Practice Address - Phone:631-957-3355
Practice Address - Fax:631-957-4378
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY175528-1174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01129991Medicaid
NYD92260Medicare UPIN
NY01129991Medicaid