Provider Demographics
NPI:1942206511
Name:KIBRIA, MIR (MD)
Entity Type:Individual
Prefix:
First Name:MIR
Middle Name:
Last Name:KIBRIA
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 1:68 S SERVICE RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2354
Mailing Address - Country:US
Mailing Address - Phone:516-945-3000
Mailing Address - Fax:
Practice Address - Street 1:300 COMMUNITY DR
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3816
Practice Address - Country:US
Practice Address - Phone:516-562-4887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-28
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0060360207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD402286600Medicaid
MDH87117Medicare UPIN
NYG400013502Medicare PIN
MD402286600Medicaid