Provider Demographics
NPI:1972517332
Name:NIERENBERG, IRA W (MD)
Entity Type:Individual
Prefix:DR
First Name:IRA
Middle Name:W
Last Name:NIERENBERG
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 1:15B JOHN HANCOCK DR
Mailing Address - Street 2:
Mailing Address - City:MONROE TWP
Mailing Address - State:NJ
Mailing Address - Zip Code:08831-4807
Mailing Address - Country:US
Mailing Address - Phone:609-395-7087
Mailing Address - Fax:609-395-7087
Practice Address - Street 1:13844 QUEENS BLVD
Practice Address - Street 2:
Practice Address - City:BRIARWOOD
Practice Address - State:NY
Practice Address - Zip Code:11435-2653
Practice Address - Country:US
Practice Address - Phone:718-523-9811
Practice Address - Fax:718-523-9823
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2022-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY162001207RG0100X
NJMA05099500207RG0100X
WI66715207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01063501Medicaid
NY18L711Medicare ID - Type Unspecified
NY01063501Medicaid