Provider Demographics
NPI:1295735645
Name:DE KLERK, ALAN MICHAEL (MBCHB, FAAP)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:MICHAEL
Last Name:DE KLERK
Suffix:
Gender:M
Credentials:MBCHB, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 CORNELIA ST APT 3D
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-4165
Mailing Address - Country:US
Mailing Address - Phone:321-609-1723
Mailing Address - Fax:
Practice Address - Street 1:7 CORNELIA ST APT 3D
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-4165
Practice Address - Country:US
Practice Address - Phone:321-609-1723
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2122052080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL019304000Medicaid
NY01892800Medicaid