Healthcare Provider Details

I. General information

NPI: 1528057627
Provider Name (Legal Business Name): JEFFRY KASHUK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 12/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17 ALGONQUIN CIR
AIRMONT NY
10952-5231
US

IV. Provider business mailing address

17 ALGONQUIN CIR
AIRMONT NY
10952-5231
US

V. Phone/Fax

Practice location:
  • Phone: 303-653-5700
  • Fax:
Mailing address:
  • Phone: 303-653-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberMD045576L
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number258763
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number62972
License Number StateMN
# 4
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD045576L
License Number StatePA
# 5
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301088604
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13452
License Number StateAZ
# 7
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberD71309
License Number StateMD
# 8
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDR.0023623
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: