Healthcare Provider Details

I. General information

NPI: 1659333144
Provider Name (Legal Business Name): MARIE JACQUELINE MOISES MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21517 JAMAICA AVE
QUEENS VILLAGE NY
11428-1715
US

IV. Provider business mailing address

21517 JAMAICA AVE
QUEENS VILLAGE NY
11428-1715
US

V. Phone/Fax

Practice location:
  • Phone: 718-740-3106
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number151357
License Number StateNY

VIII. Authorized Official

Name: MARIE JACQUELINE MOISES
Title or Position: SOLE PROPRIETOR
Credential:
Phone: 718-740-3106