Healthcare Provider Details

I. General information

NPI: 1497718209
Provider Name (Legal Business Name): JARED C LACORTE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 11/13/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2500 VICTORY BLVD
STATEN ISLAND NY
10314-6641
US

IV. Provider business mailing address

349 E NORTHFIELD RD
LIVINGSTON NJ
07039-4802
US

V. Phone/Fax

Practice location:
  • Phone: 718-983-1496
  • Fax: 718-982-6309
Mailing address:
  • Phone: 973-597-3333
  • Fax: 973-597-3334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number207563
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: