Provider Demographics
NPI:1386202158
Name:KLEBANOV, NIKOLAI (MD)
Entity type:Individual
Prefix:DR
First Name:NIKOLAI
Middle Name:
Last Name:KLEBANOV
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 CENTRE ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-3308
Mailing Address - Country:US
Mailing Address - Phone:508-941-7000
Mailing Address - Fax:
Practice Address - Street 1:900 CUMMINGS CTR STE 311T
Practice Address - Street 2:
Practice Address - City:BEVERLY
Practice Address - State:MA
Practice Address - Zip Code:01915-6260
Practice Address - Country:US
Practice Address - Phone:978-225-3376
Practice Address - Fax:978-560-1245
Is Sole Proprietor?:No
Enumeration Date:2019-06-05
Last Update Date:2024-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1014901207N00000X, 207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology