Healthcare Provider Details

I. General information

NPI: 1194838334
Provider Name (Legal Business Name): JACK EDWARD YOFFA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 01/06/2016
Certification Date:
Deactivation Date: 12/04/2015
Reactivation Date: 01/06/2016

III. Provider practice location address

824 FRANKLIN PARK DR
EAST SYRACUSE NY
13057-1614
US

IV. Provider business mailing address

824 FRANKLIN PARK DR
EAST SYRACUSE NY
13057-1614
US

V. Phone/Fax

Practice location:
  • Phone: 315-432-1048
  • Fax: 315-432-9219
Mailing address:
  • Phone: 315-432-1048
  • Fax: 315-432-9219

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number106115-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: