Provider Demographics
NPI:1215980271
Name:NINEBERG, ALLAN (MD)
Entity type:Individual
Prefix:
First Name:ALLAN
Middle Name:
Last Name:NINEBERG
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 1:307 CONCORD AVE
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MA
Mailing Address - Zip Code:02138-1207
Mailing Address - Country:US
Mailing Address - Phone:617-497-1484
Mailing Address - Fax:
Practice Address - Street 1:307 CONCORD AVE
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02138-1207
Practice Address - Country:US
Practice Address - Phone:617-497-1484
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-18
Last Update Date:2010-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA461072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0144789Medicaid
MA0144789Medicaid
MAB07189Medicare ID - Type Unspecified