Provider Demographics
NPI:1033276464
Name:PASQUALE, JACK ANGELO (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:ANGELO
Last Name:PASQUALE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7303 198TH ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1818
Mailing Address - Country:US
Mailing Address - Phone:718-465-0041
Mailing Address - Fax:718-465-4224
Practice Address - Street 1:7303 198TH ST
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1818
Practice Address - Country:US
Practice Address - Phone:718-465-0041
Practice Address - Fax:718-465-4224
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164513-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02330909Medicaid
NY2243778OtherCIGNA
E38244Medicare UPIN
NY02330909Medicaid