=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235690058
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JACQUELINE RUBI FLEURISCAR MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2019
-----------------------------------------------------
Last Update Date | 10/05/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 263 FARMINGTON AVE
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06030-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-679-2792
-----------------------------------------------------
Fax | 860-679-2792
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 263 FARMINGTON AVE
-----------------------------------------------------
City | FARMINGTON
-----------------------------------------------------
State | CT
-----------------------------------------------------
Zip | 06030-0002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 860-224-5261
-----------------------------------------------------
Fax | 860-224-5957
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | D97118
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------