Healthcare Provider Details

I. General information

NPI: 1710895479
Provider Name (Legal Business Name): JAN NIEKE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 YORK AVE
NEW YORK NY
10065-6399
US

IV. Provider business mailing address

1230 YORK AVE
NEW YORK NY
10065-6399
US

V. Phone/Fax

Practice location:
  • Phone: 212-327-8293
  • Fax:
Mailing address:
  • Phone: 212-327-8293
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberP145586
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: