Healthcare Provider Details

I. General information

NPI: 1407122674
Provider Name (Legal Business Name): JACQUELINE MINASSO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/31/2012
Last Update Date: 12/09/2022
Certification Date: 12/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1991 MARCUS AVE SUITE 300
NEW HYDE PARK NY
11042-2123
US

IV. Provider business mailing address

11511 SHADOW CREEK PKWY
PEARLAND TX
77584-7298
US

V. Phone/Fax

Practice location:
  • Phone: 516-719-3376
  • Fax: 516-321-8514
Mailing address:
  • Phone: 713-442-0000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberT9451
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number286880
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: