Provider Demographics
NPI:1407434558
Name:VARUGHESE, JEEVAMOLE
Entity Type:Individual
Prefix:
First Name:JEEVAMOLE
Middle Name:
Last Name:VARUGHESE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8248 267TH ST
Mailing Address - Street 2:
Mailing Address - City:GLEN OAKS
Mailing Address - State:NY
Mailing Address - Zip Code:11004-1715
Mailing Address - Country:US
Mailing Address - Phone:646-280-7312
Mailing Address - Fax:
Practice Address - Street 1:8268 164TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-1121
Practice Address - Country:US
Practice Address - Phone:646-280-7312
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-31
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF-345495-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily