Provider Demographics
NPI:1457488082
Name:JACQUES, MARIE CARMEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIE
Middle Name:CARMEL
Last Name:JACQUES
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 1:1618 NEW YORK AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11746-2418
Mailing Address - Country:US
Mailing Address - Phone:631-421-2190
Mailing Address - Fax:631-421-2695
Practice Address - Street 1:1618 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-2418
Practice Address - Country:US
Practice Address - Phone:631-421-2190
Practice Address - Fax:631-421-2695
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY199373207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01920589Medicaid
NY33N111Medicare ID - Type Unspecified
NYG66052Medicare UPIN