Basic Information
| Provider Information | |||||||||
| NPI: | 1295879120 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NISSENBAUM | ||||||||
| FirstName: | ALAN | ||||||||
| MiddleName: | LEON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2152 RALPH AVE # 428 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112345406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7189987363 | ||||||||
| FaxNumber: | 7189987592 | ||||||||
| Practice Location | |||||||||
| Address1: | 3915 AVENUE V STE 104 | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112345156 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182528440 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2007 | ||||||||
| LastUpdateDate: | 09/01/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | 177636 | NY | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 01851147 | 05 | NY | MEDICAID |