Provider Demographics
NPI:1013023555
Name:HALEGOUA, JASON (PHD, MD, MBA)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:
Last Name:HALEGOUA
Suffix:
Gender:M
Credentials:PHD, MD, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 LILY DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11720-2001
Mailing Address - Country:US
Mailing Address - Phone:516-650-3636
Mailing Address - Fax:
Practice Address - Street 1:207 HALLOCK RD STE 106
Practice Address - Street 2:
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-3075
Practice Address - Country:US
Practice Address - Phone:631-675-9777
Practice Address - Fax:631-675-9778
Is Sole Proprietor?:No
Enumeration Date:2006-08-21
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY231789208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI50068Medicare UPIN