Healthcare Provider Details

I. General information

NPI: 1720645260
Provider Name (Legal Business Name): JEREMY JEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2019
Last Update Date: 06/19/2024
Certification Date: 06/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 YORK AVE
NEW YORK NY
10065-6007
US

IV. Provider business mailing address

41 ERNST AVE
BLOOMFIELD NJ
07003-4508
US

V. Phone/Fax

Practice location:
  • Phone: 347-798-9213
  • Fax:
Mailing address:
  • Phone: 973-619-8331
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT217733
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number329988-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: