Provider Demographics
NPI:1184619298
Name:KOROBOW, AMY HELEN
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:HELEN
Last Name:KOROBOW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2779
Mailing Address - Country:US
Mailing Address - Phone:631-367-5391
Mailing Address - Fax:
Practice Address - Street 1:325 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2779
Practice Address - Country:US
Practice Address - Phone:631-367-5391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-14
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY176143207K00000X, 207KA0200X, 207KI0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY0564419OtherGHI
NYF46634Medicare UPIN