1780977108 NPI number — ROCHELLE JOLY MD

Table of content: ROCHELLE JOLY MD (NPI 1780977108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1780977108 NPI number — ROCHELLE JOLY MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JOLY
Provider First Name:
ROCHELLE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LINDENBAUM
Provider Other First Name:
ROCHELLE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1780977108
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/24/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5925 15TH AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11219-5009
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
718-972-2700
Provider Business Mailing Address Fax Number:
718-532-1724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5925 15TH AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BROOKLYN
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11219-5009
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
718-972-2700
Provider Business Practice Location Address Fax Number:
718-532-1724
Provider Enumeration Date:
05/18/2011

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: 207VG0400X , with the licence number:  MD443300 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 03963191 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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