Provider Demographics
NPI:1821591132
Name:CAPOBIANCO, MICHAEL BARRY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:BARRY
Last Name:CAPOBIANCO
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 1:3 PARK PLZ STE 1
Mailing Address - Street 2:
Mailing Address - City:GLEN HEAD
Mailing Address - State:NY
Mailing Address - Zip Code:11545-1857
Mailing Address - Country:US
Mailing Address - Phone:516-801-0334
Mailing Address - Fax:
Practice Address - Street 1:3 PARK PLZ STE 1
Practice Address - Street 2:
Practice Address - City:GLEN HEAD
Practice Address - State:NY
Practice Address - Zip Code:11545-1857
Practice Address - Country:US
Practice Address - Phone:516-801-0334
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-03-13
Last Update Date:2018-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY143830207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
HA$$$$$$$$$OtherNY STATE