Healthcare Provider Details

I. General information

NPI: 1326278219
Provider Name (Legal Business Name): JORGE ERNESTO MEJIA-CORLETTO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2009
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1476 DEER PARK AVE STE 2
NORTH BABYLON NY
11703-1200
US

IV. Provider business mailing address

1476 DEER PARK AVE STE 2
NORTH BABYLON NY
11703-1200
US

V. Phone/Fax

Practice location:
  • Phone: 631-462-1184
  • Fax: 631-462-1187
Mailing address:
  • Phone: 631-462-1184
  • Fax: 631-462-1187

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number280795-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: