Provider Demographics
NPI:1073589602
Name:VIRGO, JEFFERY JASON (OTC, OPA-C, LSA)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:JASON
Last Name:VIRGO
Suffix:
Gender:M
Credentials:OTC, OPA-C, LSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 MALLARD WAY
Mailing Address - Street 2:
Mailing Address - City:PEEKSKILL
Mailing Address - State:NY
Mailing Address - Zip Code:10566-4178
Mailing Address - Country:US
Mailing Address - Phone:914-737-5608
Mailing Address - Fax:
Practice Address - Street 1:234 E 149TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451-5504
Practice Address - Country:US
Practice Address - Phone:718-579-5919
Practice Address - Fax:718-579-4620
Is Sole Proprietor?:No
Enumeration Date:2006-02-24
Last Update Date:2023-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
246ZS0410X
NYO000066-246ZX2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZX2200XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherOrthopedic Assistant
No246ZS0410XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Technologist