=====================================================
General NPI Number Information
=====================================================
NPI Number | 1225426018
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JACKIE P. ORFANOS,MD, PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/31/2014
-----------------------------------------------------
Last Update Date | 01/12/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 700 OLD COUNTRY RD SUITE 200
-----------------------------------------------------
City | PLAINVIEW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11803-4932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-681-5801
-----------------------------------------------------
Fax | 516-681-5861
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 700 OLD COUNTRY RD SUITE 200
-----------------------------------------------------
City | PLAINVIEW
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11803-4932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-681-5801
-----------------------------------------------------
Fax | 516-681-5861
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD
-----------------------------------------------------
Name | DR. JACKIE P. ORFANOS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 516-993-1207
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 180070
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------