Provider Demographics
NPI:1194838334
Name:YOFFA, JACK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EDWARD
Last Name:YOFFA
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 1:824 FRANKLIN PARK DR
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-1614
Mailing Address - Country:US
Mailing Address - Phone:315-432-1048
Mailing Address - Fax:315-432-9219
Practice Address - Street 1:824 FRANKLIN PARK DR
Practice Address - Street 2:
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-1614
Practice Address - Country:US
Practice Address - Phone:315-432-1048
Practice Address - Fax:315-432-9219
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2016-01-06
Deactivation Date:2015-12-04
Deactivation Code:
Reactivation Date:2016-01-06
Provider Licenses
StateLicense IDTaxonomies
NY106115-1173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00572349Medicaid
NY00572349Medicaid
NYB80998Medicare UPIN