MEDICARE: DR. DOMINIQUE M. JAN 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	204F00000X	Transplant Surgery Physician	0024381	NY
2	2086S0120X	Pediatric Surgery Physician	250182	NY

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790726982
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DOMINIQUE M. JAN MD

Provider Business Mailing Address
First Line	:	3355 BAINBRIDGE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-2801
Country	:	US
Telephone Number	:	718-920-7200
Fax Number	:	718-547-2929

Provider Business Practice Location Address
First Line	:	3355 BAINBRIDGE AVE
Second Line	:
City	:	BRONX
State	:	NY
Zip	:	10467-2801
Country	:	US
Telephone Number	:	718-920-7200
Fax Number	:	718-547-2929

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

Provider Enumeration Date	:	06/09/2006
Last Update Date	:	01/19/2012

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