Provider Demographics
NPI:1619070083
Name:NODELMAN, SAMUEL G (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:G
Last Name:NODELMAN
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 1:147A W END AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-4808
Mailing Address - Country:US
Mailing Address - Phone:718-891-5251
Mailing Address - Fax:718-891-7383
Practice Address - Street 1:147A W END AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-4808
Practice Address - Country:US
Practice Address - Phone:718-891-5251
Practice Address - Fax:718-891-7383
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152116207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00780887Medicaid
NYA64656Medicare UPIN
NY89A991Medicare ID - Type Unspecified