Provider Demographics
NPI:1407849292
Name:KASSOFF, JORDAN (MD)
Entity Type:Individual
Prefix:
First Name:JORDAN
Middle Name:
Last Name:KASSOFF
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 1:63 SHAKER RD
Mailing Address - Street 2:SUTIE 101
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12204-1030
Mailing Address - Country:US
Mailing Address - Phone:518-434-1042
Mailing Address - Fax:518-434-4327
Practice Address - Street 1:63 SHAKER RD
Practice Address - Street 2:SUTIE 101
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12204-1030
Practice Address - Country:US
Practice Address - Phone:518-434-1042
Practice Address - Fax:518-434-4327
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2009-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174732207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01413056Medicaid
F21614Medicare UPIN
NY01413056Medicaid