Provider Demographics
NPI:1538167127
Name:UNDERBERG, JAMES A (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:A
Last Name:UNDERBERG
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 1:110 E 55TH ST FL 9
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10022-4540
Mailing Address - Country:US
Mailing Address - Phone:212-207-1959
Mailing Address - Fax:855-680-3844
Practice Address - Street 1:110 E 55TH ST FL 9
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022-4540
Practice Address - Country:US
Practice Address - Phone:212-207-1959
Practice Address - Fax:855-680-3844
Is Sole Proprietor?:No
Enumeration Date:2005-07-08
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY171903207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY011293406Medicaid
NYD92174Medicare UPIN
NY011293406Medicaid