Healthcare Provider Details

I. General information

NPI: 1003127366
Provider Name (Legal Business Name): VIVIAN JOLLEY BEA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: VIVIAN ALICE JOLLEY M.D.

II. Dates (important events)

Enumeration Date: 07/01/2010
Last Update Date: 02/13/2025
Certification Date: 02/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 6TH ST
BROOKLYN NY
11215-3609
US

IV. Provider business mailing address

506 6TH ST
BROOKLYN NY
11215-3609
US

V. Phone/Fax

Practice location:
  • Phone: 718-780-3288
  • Fax: 718-780-3154
Mailing address:
  • Phone: 718-780-3288
  • Fax: 718-780-3154

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA10160900
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberQ9291
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLL32911
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number300153-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: