Provider Demographics
NPI:1013955285
Name:KLEBANOV, IRINA (DO)
Entity Type:Individual
Prefix:DR
First Name:IRINA
Middle Name:
Last Name:KLEBANOV
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 OCEANA DR E
Mailing Address - Street 2:6C
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11235-6684
Mailing Address - Country:US
Mailing Address - Phone:718-496-7679
Mailing Address - Fax:
Practice Address - Street 1:1517 VOORHIES AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-3970
Practice Address - Country:US
Practice Address - Phone:718-676-4500
Practice Address - Fax:718-942-5649
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY223026207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02221167Medicaid
NY02221167Medicaid
NYH67482Medicare UPIN