Provider Demographics
NPI:1801859954
Name:MEDETSKY, HERBERT ALAN
Entity Type:Individual
Prefix:
First Name:HERBERT
Middle Name:ALAN
Last Name:MEDETSKY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8707 FLATLANDS AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-3609
Mailing Address - Country:US
Mailing Address - Phone:718-257-7777
Mailing Address - Fax:718-257-8990
Practice Address - Street 1:8707 FLATLANDS AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-3609
Practice Address - Country:US
Practice Address - Phone:718-257-7777
Practice Address - Fax:718-257-8990
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-10
Last Update Date:2010-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007048103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYS05218Medicare UPIN
NYV17641Medicare ID - Type Unspecified