Provider Demographics
NPI:1083954648
Name:JACQUES DUPERVAL, MD, FICS, FACS, PC
Entity Type:Organization
Organization Name:JACQUES DUPERVAL, MD, FICS, FACS, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JACQUES
Authorized Official - Middle Name:
Authorized Official - Last Name:DUPERVAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-783-5168
Mailing Address - Street 1:60 PLAZA STREET EAST
Mailing Address - Street 2:SUITE S-3
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238
Mailing Address - Country:US
Mailing Address - Phone:718-783-5168
Mailing Address - Fax:718-783-0408
Practice Address - Street 1:60 PLAZA STREET EAST
Practice Address - Street 2:SUITE S-3
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238
Practice Address - Country:US
Practice Address - Phone:718-783-5168
Practice Address - Fax:718-783-0408
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-19
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty