Provider Demographics
NPI:1346405610
Name:CAPORUSCIO, JESSICA LEIGH (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LEIGH
Last Name:CAPORUSCIO
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 1:325 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743-2779
Mailing Address - Country:US
Mailing Address - Phone:631-367-5052
Mailing Address - Fax:631-547-5349
Practice Address - Street 1:325 PARK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2779
Practice Address - Country:US
Practice Address - Phone:631-367-5052
Practice Address - Fax:631-547-5349
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY249647207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03026217Medicaid
NY03026217Medicaid