Provider Demographics
NPI:1790846046
Name:VALDBERG, GRIGORY JACOB (MD)
Entity type:Individual
Prefix:DR
First Name:GRIGORY
Middle Name:JACOB
Last Name:VALDBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1410 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11204-4101
Mailing Address - Country:US
Mailing Address - Phone:718-837-1031
Mailing Address - Fax:718-837-1671
Practice Address - Street 1:1410 W 3RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11204-4101
Practice Address - Country:US
Practice Address - Phone:718-837-1031
Practice Address - Fax:718-837-1671
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY202572261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000000050434OtherGHI HMO
NY0B7301OtherEMPIRE
NY2699905OtherGHI
NYPC2348OtherCENTER CARE
NY0P555POtherHIP
NY5251450OtherAETNA
NY26P3881OtherPRESBYTERIAN
NY202572OtherLICENSE
NYBK0214503OtherAMERICHOICE
NY2C8442OtherNELTH NET
NY5026928OtherCIGNA
NY01648975Medicaid
NY12-01328OtherUHC
NY137072OtherWELL CARE
NYP1046880OtherOXFORD
NY202572-C79OtherHEALTH FIRST
NY01648975Medicaid