Provider Demographics
NPI:1760468854
Name:KLEINER, MYRON I (MD)
Entity Type:Individual
Prefix:
First Name:MYRON
Middle Name:I
Last Name:KLEINER
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 1:180 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-8427
Mailing Address - Country:US
Mailing Address - Phone:631-665-4466
Mailing Address - Fax:631-665-2716
Practice Address - Street 1:180 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-8427
Practice Address - Country:US
Practice Address - Phone:631-665-4466
Practice Address - Fax:631-665-2716
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2007-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY142909174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00758452Medicaid
NYB87397Medicare UPIN
NY90A551Medicare ID - Type Unspecified