Healthcare Provider Details

I. General information

NPI: 1053932293
Provider Name (Legal Business Name): JAISON JACOB JOHN DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2020
Last Update Date: 05/28/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 OLD COUNTRY RD
PLAINVIEW NY
11803-5013
US

IV. Provider business mailing address

2401 S 31ST ST # MSAG407Q
TEMPLE TX
76508-0001
US

V. Phone/Fax

Practice location:
  • Phone: 516-433-3600
  • Fax:
Mailing address:
  • Phone: 254-724-9290
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number342481
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberBP10072178
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberBP10072178
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: