Provider Demographics
NPI:1538371331
Name:WOLBERG, JAMES PETER (MD)
Entity type:Individual
Prefix:DR
First Name:JAMES
Middle Name:PETER
Last Name:WOLBERG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:199 CLINTON ST
Mailing Address - Street 2:#4
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11201-6259
Mailing Address - Country:US
Mailing Address - Phone:718-422-0192
Mailing Address - Fax:
Practice Address - Street 1:1ST AVE & 16TH ST
Practice Address - Street 2:BERNSTEIN PAVILION
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10003
Practice Address - Country:US
Practice Address - Phone:212-420-4566
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1917032084A0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP1075026Medicaid
NY01135710Medicare ID - Type Unspecified
NYP1075026Medicaid