Healthcare Provider Details

I. General information

NPI: 1790778264
Provider Name (Legal Business Name): JACQUELIN EMMANUEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/30/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 E 116TH ST
NEW YORK NY
10029-1150
US

IV. Provider business mailing address

8432 MIDLAND PKWY
JAMAICA NY
11432-2219
US

V. Phone/Fax

Practice location:
  • Phone: 212-828-7700
  • Fax: 212-828-7800
Mailing address:
  • Phone: 718-658-7116
  • Fax: 212-828-7800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number135799
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: