Provider Demographics
NPI:1336164292
Name:HALTIWANGER, KIMBERLY STONE (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:STONE
Last Name:HALTIWANGER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:646 COMMACK RD
Mailing Address - Street 2:
Mailing Address - City:COMMACK
Mailing Address - State:NY
Mailing Address - Zip Code:11725-5404
Mailing Address - Country:US
Mailing Address - Phone:631-499-4114
Mailing Address - Fax:631-499-1468
Practice Address - Street 1:646 COMMACK RD
Practice Address - Street 2:
Practice Address - City:COMMACK
Practice Address - State:NY
Practice Address - Zip Code:11725-5404
Practice Address - Country:US
Practice Address - Phone:631-499-4114
Practice Address - Fax:631-499-1468
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188281208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01821338Medicaid
NY00401381Medicaid
NY01821338Medicaid