Healthcare Provider Details

I. General information

NPI: 1851352926
Provider Name (Legal Business Name): JASON CHAMIKLES D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 03/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7309 MYRTLE AVE
GLENDALE NY
11385-7418
US

IV. Provider business mailing address

7309 MYRTLE AVE
GLENDALE NY
11385-7418
US

V. Phone/Fax

Practice location:
  • Phone: 718-497-1429
  • Fax: 646-357-9739
Mailing address:
  • Phone: 718-497-1429
  • Fax: 646-357-9739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number192757
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number192757-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: