Healthcare Provider Details

I. General information

NPI: 1073589602
Provider Name (Legal Business Name): JEFFERY JASON VIRGO OTC, OPA-C, LSA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2006
Last Update Date: 02/02/2023
Certification Date: 02/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 E 149TH ST
BRONX NY
10451-5504
US

IV. Provider business mailing address

703 MALLARD WAY
PEEKSKILL NY
10566-4178
US

V. Phone/Fax

Practice location:
  • Phone: 718-579-5919
  • Fax: 718-579-4620
Mailing address:
  • Phone: 914-737-5608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code246ZX2200X
TaxonomyOrthopedic Assistant
License NumberO000066-
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: