Healthcare Provider Details

I. General information

NPI: 1639740079
Provider Name (Legal Business Name): JENNIFER MUGAVERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2021
Last Update Date: 07/07/2021
Certification Date: 07/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 E BETHPAGE RD STE 5
PLAINVIEW NY
11803-4228
US

IV. Provider business mailing address

2 ROBERT DR
HUNTINGTON NY
11743-5344
US

V. Phone/Fax

Practice location:
  • Phone: 516-731-5588
  • Fax:
Mailing address:
  • Phone: 631-278-0597
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: