Provider Demographics
NPI:1437191236
Name:WATTENBERG, DEBRA JOY (MD)
Entity type:Individual
Prefix:DR
First Name:DEBRA
Middle Name:JOY
Last Name:WATTENBERG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4952
Mailing Address - Country:US
Mailing Address - Phone:212-288-3200
Mailing Address - Fax:212-288-3226
Practice Address - Street 1:875 5TH AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4952
Practice Address - Country:US
Practice Address - Phone:212-288-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-13
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY178869207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF21228Medicare UPIN
NY29K882Medicare ID - Type Unspecified