Provider Demographics
NPI:1952449829
Name:O'BRIEN, DENNIS S (MD)
Entity Type:Individual
Prefix:
First Name:DENNIS
Middle Name:S
Last Name:O'BRIEN
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 1:9 CAREY RD
Mailing Address - Street 2:
Mailing Address - City:QUEENSBURY
Mailing Address - State:NY
Mailing Address - Zip Code:12804-7880
Mailing Address - Country:US
Mailing Address - Phone:518-761-0300
Mailing Address - Fax:518-824-2388
Practice Address - Street 1:102 RACE TRACK RD STE 1
Practice Address - Street 2:
Practice Address - City:TICONDEROGA
Practice Address - State:NY
Practice Address - Zip Code:12883-4004
Practice Address - Country:US
Practice Address - Phone:518-585-6708
Practice Address - Fax:518-585-3260
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY154766207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00774992Medicaid
NY134AS1OtherBLUE CROSS BLUE SHIELD
NY154766-0OtherWORKERS COMPENSATION AUTH
NY2670OtherVYTRA ID #
NY49025OtherMDNY PCP ID #
NYCP263OtherOXFORD PROVIDER #
NY841553OtherUNITED HEALTHCARE
NY061638829OtherTAX ID #
NY49025OtherMDNY PCP ID #
NY061638829OtherTAX ID #