Healthcare Provider Details

I. General information

NPI: 1336181866
Provider Name (Legal Business Name): JESSY COLAH MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/11/2006
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

812 BONNIE DR
BALDWIN NY
11510-4521
US

IV. Provider business mailing address

PO BOX 161
BALDWIN NY
11510-0161
US

V. Phone/Fax

Practice location:
  • Phone: 718-753-4585
  • Fax: 718-540-6243
Mailing address:
  • Phone: 718-753-4585
  • Fax: 718-540-6243

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number167666
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier01889990
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: