Provider Demographics
NPI:1295879120
Name:NISSENBAUM, ALAN LEON (MD)
Entity type:Individual
Prefix:DR
First Name:ALAN
Middle Name:LEON
Last Name:NISSENBAUM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2152 RALPH AVE # 428
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5406
Mailing Address - Country:US
Mailing Address - Phone:718-998-7363
Mailing Address - Fax:718-998-7592
Practice Address - Street 1:3915 AVENUE V STE 104
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234-5156
Practice Address - Country:US
Practice Address - Phone:718-252-8440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2022-09-01
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY177636207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01851147Medicaid
NY35F782Medicare PIN
NYE89065Medicare UPIN