1073589602 NPI number — MR. JEFFERY JASON VIRGO OTC, OPA-C, LSA

Table of content: MR. JEFFERY JASON VIRGO OTC, OPA-C, LSA (NPI 1073589602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073589602 NPI number — MR. JEFFERY JASON VIRGO OTC, OPA-C, LSA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
VIRGO
Provider First Name:
JEFFERY
Provider Middle Name:
JASON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
OTC, OPA-C, LSA
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:
1073589602
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
703 MALLARD WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PEEKSKILL
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
10566-4178
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
914-737-5608
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
234 E 149TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BRONX
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
10451-5504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-579-5919
Provider Business Practice Location Address Fax Number:
718-579-4620
Provider Enumeration Date:
02/24/2006

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: 246ZS0410X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246ZX2200X , with the licence number: O000066- , 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)