Provider Demographics
NPI:1407835051
Name:MOLINE, JACQUELINE M (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:M
Last Name:MOLINE
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 1:1212 5TH AVE
Mailing Address - Street 2:SUITE 1A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-5210
Mailing Address - Country:US
Mailing Address - Phone:212-241-5555
Mailing Address - Fax:212-241-5658
Practice Address - Street 1:1212 5TH AVE
Practice Address - Street 2:SUITE 1A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-5210
Practice Address - Country:US
Practice Address - Phone:212-241-5555
Practice Address - Fax:212-241-5658
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY184671174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG82132Medicare UPIN
NY7T8202Medicare ID - Type Unspecified