Healthcare Provider Details

I. General information

NPI: 1487751202
Provider Name (Legal Business Name): JEREMY S ROCHESTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 11/19/2021
Certification Date: 11/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

158 CENTRAL AVE.
BETHPAGE NY
11714
US

IV. Provider business mailing address

2800 MARCUS AVE
NEW HYDE PARK NY
11042-1113
US

V. Phone/Fax

Practice location:
  • Phone: 516-758-8600
  • Fax:
Mailing address:
  • Phone: 516-622-6076
  • Fax: 516-622-6075

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number222184
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: