Provider Demographics
NPI:1871523662
Name:FELLENBAUM, PAUL STANLEY (MD)
Entity type:Individual
Prefix:DR
First Name:PAUL
Middle Name:STANLEY
Last Name:FELLENBAUM
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Gender:M
Credentials:MD
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Mailing Address - Street 1:2 KROSS KEYS DR
Mailing Address - Street 2:SUITE 103
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-1466
Mailing Address - Country:US
Mailing Address - Phone:518-438-2751
Mailing Address - Fax:518-438-2753
Practice Address - Street 1:2 KROSS KEYS DR
Practice Address - Street 2:SUITE 103
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-1466
Practice Address - Country:US
Practice Address - Phone:518-438-2751
Practice Address - Fax:518-438-2753
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2011-04-26
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Provider Licenses
StateLicense IDTaxonomies
NY208750174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01912289Medicaid
F41080Medicare UPIN
NY51487EMedicare PIN