Provider Demographics
NPI:1497718209
Name:LACORTE, JARED C (MD)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:C
Last Name:LACORTE
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 1:349 E NORTHFIELD RD
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-4802
Mailing Address - Country:US
Mailing Address - Phone:973-597-3333
Mailing Address - Fax:973-597-3334
Practice Address - Street 1:2500 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6641
Practice Address - Country:US
Practice Address - Phone:718-983-1496
Practice Address - Fax:718-982-6309
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-11
Last Update Date:2014-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM207563174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0090069Medicaid
NY2368490Medicaid
NJ0090069Medicaid