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General NPI Number Information
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NPI Number | 1790726982
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Entity Type | Individual
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Provider Name | DOMINIQUE M. JAN MD
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Gender | Male
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Dates
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Enumeration Date | 06/09/2006
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Last Update Date | 01/19/2012
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Provider Practice Location Address
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Address Line | 3355 BAINBRIDGE AVE
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City | BRONX
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State | NY
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Zip | 10467-2801
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Country | US
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Telephone | 718-920-7200
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Fax | 718-547-2929
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Provider Business Mailing Address
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Address Line | 3355 BAINBRIDGE AVE
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City | BRONX
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State | NY
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Zip | 10467-2801
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Country | US
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Telephone | 718-920-7200
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Fax | 718-547-2929
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 204F00000X
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Taxonomy Name | Transplant Surgery Physician
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License Number | 0024381
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License Number State | NY
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Taxonomy #2
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Taxonomy Code | 2086S0120X
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Taxonomy Name | Pediatric Surgery Physician
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License Number | 250182
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License Number State | NY
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