Healthcare Provider Details

I. General information

NPI: 1386997930
Provider Name (Legal Business Name): MUKAI HEATHER JARAVAZA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MUKAI HEATHER JARAVAZA M.D

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 11/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

147 LAKE STREET GREATER HUDSON VALLEY FAMILY HEALTH CENT
NEWBURGH NY
12550
US

IV. Provider business mailing address

2570 ROUTE 9W SUITE 10
CORNWALL NY
12518-1323
US

V. Phone/Fax

Practice location:
  • Phone: 845-563-8000
  • Fax:
Mailing address:
  • Phone: 845-220-3100
  • Fax: 845-534-2940

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number267143
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: