MEDICARE: NIRMALA AMELIA D'AUGUSTE DEJESUS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	340697	NY

General Provider Information

NPI Number	:	1063152767
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIRMALA AMELIA D'AUGUSTE DEJESUS MD

Provider Business Mailing Address
First Line	:	260 MAIN ST STE 1
Second Line	:
City	:	ISLIP
State	:	NY
Zip	:	11751-3450
Country	:	US
Telephone Number	:	631-581-4481
Fax Number	:

Provider Business Practice Location Address
First Line	:	260 MAIN ST STE 1
Second Line	:
City	:	ISLIP
State	:	NY
Zip	:	11751-3450
Country	:	US
Telephone Number	:	631-581-4481
Fax Number	:	631-548-6823

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/30/2022
Last Update Date	:	12/09/2025

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