Provider Demographics
NPI:1013009190
Name:MABY, JAN (DO)
Entity Type:Individual
Prefix:DR
First Name:JAN
Middle Name:
Last Name:MABY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:900 WASHINGTON RD
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:NY
Mailing Address - Zip Code:10996-1109
Mailing Address - Country:US
Mailing Address - Phone:845-938-5959
Mailing Address - Fax:845-938-2306
Practice Address - Street 1:900 WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:WEST POINT
Practice Address - State:NY
Practice Address - Zip Code:10996-1109
Practice Address - Country:US
Practice Address - Phone:845-938-5959
Practice Address - Fax:845-938-2306
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY173458207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01750045Medicaid
E94826Medicare UPIN
94F751Medicare ID - Type Unspecified