Provider Demographics
NPI:1144210196
Name:DELMONT, JACQUELINE (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:DELMONT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11520-2243
Mailing Address - Country:US
Mailing Address - Phone:516-377-8014
Mailing Address - Fax:516-377-8017
Practice Address - Street 1:55 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:NY
Practice Address - Zip Code:11520-2243
Practice Address - Country:US
Practice Address - Phone:516-377-8014
Practice Address - Fax:516-377-8017
Is Sole Proprietor?:No
Enumeration Date:2005-10-21
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY212962207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01947942OtherMEDICAID
NYG88348Medicare UPIN