Provider Demographics
NPI:1649221789
Name:KANNER, BARRY JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:BARRY
Middle Name:JACOB
Last Name:KANNER
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 1:3030 WESTCHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:PURCHASE
Mailing Address - State:NY
Mailing Address - Zip Code:10577-2574
Mailing Address - Country:US
Mailing Address - Phone:914-607-5880
Mailing Address - Fax:914-848-8751
Practice Address - Street 1:3030 WESTCHESTER AVE
Practice Address - Street 2:
Practice Address - City:PURCHASE
Practice Address - State:NY
Practice Address - Zip Code:10577-2574
Practice Address - Country:US
Practice Address - Phone:914-607-5880
Practice Address - Fax:914-848-8751
Is Sole Proprietor?:No
Enumeration Date:2006-05-13
Last Update Date:2016-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1879392085R0204X
CT0441912085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01692662Medicaid
NY01692662Medicaid
NY01692662Medicaid