1194935122 NPI number — JORDAN S. DUBOW MD

Table of content: JORDAN S. DUBOW MD (NPI 1194935122)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194935122 NPI number — JORDAN S. DUBOW MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DUBOW
Provider First Name:
JORDAN
Provider Middle Name:
S.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194935122
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/12/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
20 GRAND ST
Provider Second Line Business Mailing Address:
CBO - 3RD FLOOR
Provider Business Mailing Address City Name:
WARWICK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10990-1035
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
845-987-3973
Provider Business Mailing Address Fax Number:
845-987-5979

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
257 LAFAYETTE AVE
Provider Second Line Business Practice Location Address:
SUITE 330
Provider Business Practice Location Address City Name:
SUFFERN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10901-4830
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
845-368-8808
Provider Business Practice Location Address Fax Number:
845-368-5608
Provider Enumeration Date:
05/22/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2084N0400X , with the licence number:  036-118122 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084N0400X , with the licence number: 255345 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 255345 . This is a "NY LICENSE #" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 036-118122 . This is a "IL STATE LIC" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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