Provider Demographics
NPI:1639467756
Name:BANNET, MALKA MERAV (DO)
Entity Type:Individual
Prefix:
First Name:MALKA
Middle Name:MERAV
Last Name:BANNET
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MALKA
Other - Middle Name:MERAV
Other - Last Name:ABRAHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1111 AMSTERDAM AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-1716
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:75 E NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-4532
Practice Address - Country:US
Practice Address - Phone:973-436-1460
Practice Address - Fax:973-422-9390
Is Sole Proprietor?:No
Enumeration Date:2011-07-11
Last Update Date:2019-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276073-1207R00000X
NJ25MB10390000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00122324700Medicaid