Provider Demographics
NPI:1528197118
Name:TEITELBAUM, SAMUEL D (C-PED)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:D
Last Name:TEITELBAUM
Suffix:
Gender:M
Credentials:C-PED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:928 46TH ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11219-2331
Mailing Address - Country:US
Mailing Address - Phone:718-782-0600
Mailing Address - Fax:718-782-0611
Practice Address - Street 1:166 ROSS ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11211
Practice Address - Country:US
Practice Address - Phone:718-782-0600
Practice Address - Fax:718-782-0611
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-02
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20546174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6039400001Medicare NSC