Provider Demographics
NPI:1851393847
Name:NOMBERG, ADAM T (MD)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:T
Last Name:NOMBERG
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 1:100 MANETTO HILL RD
Mailing Address - Street 2:SUITE 105
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-1311
Mailing Address - Country:US
Mailing Address - Phone:516-935-4141
Mailing Address - Fax:516-935-1770
Practice Address - Street 1:100 MANETTO HILL RD
Practice Address - Street 2:SUITE 105
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-1311
Practice Address - Country:US
Practice Address - Phone:516-935-4141
Practice Address - Fax:516-935-1770
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197495174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01753828Medicaid
NY67X442Medicare ID - Type Unspecified
NY01753828Medicaid