=====================================================
General NPI Number Information
=====================================================
NPI Number | 1245247949
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW ANGELO JACONO MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/02/2006
-----------------------------------------------------
Last Update Date | 02/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 440-450 NORTHERN BLVD
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-773-4646
-----------------------------------------------------
Fax | 516-773-1360
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 440 NORTHERN BLVD
-----------------------------------------------------
City | GREAT NECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11021
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-773-4646
-----------------------------------------------------
Fax | 516-773-1360
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Y00000X
-----------------------------------------------------
Taxonomy Name | Otolaryngology Physician
-----------------------------------------------------
License Number | 2089311
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | 2089311
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------