Provider Demographics
NPI:1225697832
Name:MALDONADO, JORGE
Entity Type:Individual
Prefix:
First Name:JORGE
Middle Name:
Last Name:MALDONADO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14202 20TH AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11351-3000
Mailing Address - Country:US
Mailing Address - Phone:347-542-5658
Mailing Address - Fax:
Practice Address - Street 1:507 BEACH 64TH ST
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11692-1326
Practice Address - Country:US
Practice Address - Phone:917-816-5582
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY7486501163W00000X
NY748650-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse