Healthcare Provider Details

I. General information

NPI: 1902987134
Provider Name (Legal Business Name): JEAN-ROBERT BOURSIQUOT M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 04/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

97-03 SPRINGFIELD BLVD.
QUEENS VILLAGE NY
11429
US

IV. Provider business mailing address

11 TALON WAY
DIX HILLS NY
11746-6238
US

V. Phone/Fax

Practice location:
  • Phone: 718-465-7200
  • Fax: 718-465-0407
Mailing address:
  • Phone: 631-242-0379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number156767
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: