Provider Demographics
NPI:1740367630
Name:KOROBOV, IRINA (MD)
Entity type:Individual
Prefix:
First Name:IRINA
Middle Name:
Last Name:KOROBOV
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 1:100 DEMAREST AVE
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-1738
Mailing Address - Country:US
Mailing Address - Phone:201-660-7540
Mailing Address - Fax:
Practice Address - Street 1:1130 BRIGHTON BEACH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11235-5555
Practice Address - Country:US
Practice Address - Phone:718-918-4574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2010-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1699442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01111339Medicaid
NY02F291Medicare PIN