Provider Demographics
NPI:1902918279
Name:FAYNGERSH, MIRON (MD)
Entity Type:Individual
Prefix:
First Name:MIRON
Middle Name:
Last Name:FAYNGERSH
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 1:745 OCEAN PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11230-1113
Mailing Address - Country:US
Mailing Address - Phone:718-677-9700
Mailing Address - Fax:718-859-5969
Practice Address - Street 1:745 OCEAN PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11230-1113
Practice Address - Country:US
Practice Address - Phone:718-677-9700
Practice Address - Fax:718-859-5969
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY197845174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1553699Medicaid
NY1553699Medicaid
OOA191Medicare ID - Type Unspecified