Provider Demographics
NPI:1871662908
Name:IRA KLONSKY
Entity Type:Organization
Organization Name:IRA KLONSKY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETER
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:
Authorized Official - Last Name:KLONSKY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:516-568-9119
Mailing Address - Street 1:765 KEARNY DR
Mailing Address - Street 2:
Mailing Address - City:VALLEY STREAM
Mailing Address - State:NY
Mailing Address - Zip Code:11581-3626
Mailing Address - Country:US
Mailing Address - Phone:516-568-9119
Mailing Address - Fax:
Practice Address - Street 1:210 E SUNRISE HWY
Practice Address - Street 2:SUITE 303
Practice Address - City:VALLEY STREAM
Practice Address - State:NY
Practice Address - Zip Code:11581-1329
Practice Address - Country:US
Practice Address - Phone:516-568-9119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY137566174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00775159Medicaid
NYB14915Medicare UPIN
NY52F142Medicare ID - Type Unspecified