Provider Demographics
NPI:1528381902
Name:GOOTMAN, JANE
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:
Last Name:GOOTMAN
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 1:12 S MOUNTAIN PASS
Mailing Address - Street 2:
Mailing Address - City:KATONAH
Mailing Address - State:NY
Mailing Address - Zip Code:10536-2634
Mailing Address - Country:US
Mailing Address - Phone:917-690-0001
Mailing Address - Fax:
Practice Address - Street 1:422 CHURCH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11218-3108
Practice Address - Country:US
Practice Address - Phone:718-686-2727
Practice Address - Fax:718-535-0855
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2010-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY047990-1183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist