Healthcare Provider Details

I. General information

NPI: 1285694240
Provider Name (Legal Business Name): JACK SKOWRON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 CLOVE RD
STATEN ISLAND NY
10301-3627
US

IV. Provider business mailing address

55 WATER ST FL 2
NEW YORK NY
10041-0010
US

V. Phone/Fax

Practice location:
  • Phone: 718-816-6440
  • Fax: 718-816-3739
Mailing address:
  • Phone: 646-680-2888
  • Fax: 516-542-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number150345
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: