1225197866 NPI number — MS. JACQUELINE PANDOLFI N.P.

Table of content: MS. JACQUELINE PANDOLFI N.P. (NPI 1225197866)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225197866 NPI number — MS. JACQUELINE PANDOLFI N.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PANDOLFI
Provider First Name:
JACQUELINE
Provider Middle Name:
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
N.P.
Provider Gender Code:
F

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:
1225197866
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/14/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
900 MERCHANTS CONCOURSE STE 216
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WESTBURY
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11590-5114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-226-8373
Provider Business Mailing Address Fax Number:
844-632-8265

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
12 MEDICAL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORT JEFFERSON STATION
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11776-1588
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
631-331-4400
Provider Business Practice Location Address Fax Number:
631-331-3190
Provider Enumeration Date:
12/08/2006

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: 363LW0102X , with the licence number:  388956-1 , 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: 388956 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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