Healthcare Provider Details

I. General information

NPI: 1376170712
Provider Name (Legal Business Name): JERRY CUENCA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2020
Last Update Date: 11/03/2025
Certification Date: 11/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 NICOLLS RD
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

101 NICOLLS RD
STONY BROOK NY
11794-0001
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-2968
  • Fax:
Mailing address:
  • Phone: 631-444-2968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number95701
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: