Provider Demographics
NPI:1740455765
Name:DEBRA J. WATTENBERG, M.D.,P.C
Entity type:Organization
Organization Name:DEBRA J. WATTENBERG, M.D.,P.C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:JOY
Authorized Official - Last Name:WATTENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-288-3200
Mailing Address - Street 1:875 5TH AVE
Mailing Address - Street 2:69TH ST, 2B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4952
Mailing Address - Country:US
Mailing Address - Phone:212-288-3200
Mailing Address - Fax:212-288-3226
Practice Address - Street 1:875 5TH AVE
Practice Address - Street 2:69TH ST, 2B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4952
Practice Address - Country:US
Practice Address - Phone:212-288-3200
Practice Address - Fax:212-288-3226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-30
Last Update Date:2008-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178869173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF21228Medicare UPIN