Provider Demographics
NPI:1558622464
Name:SOPHIR, JAN PHYLLIS
Entity Type:Individual
Prefix:MRS
First Name:JAN
Middle Name:PHYLLIS
Last Name:SOPHIR
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 1:30 CHERRYWOOD LN
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050-4534
Mailing Address - Country:US
Mailing Address - Phone:516-443-8061
Mailing Address - Fax:516-627-4999
Practice Address - Street 1:30 CHERRYWOOD LN
Practice Address - Street 2:
Practice Address - City:PORT WASHINGTON
Practice Address - State:NY
Practice Address - Zip Code:11050-4534
Practice Address - Country:US
Practice Address - Phone:516-443-8061
Practice Address - Fax:516-627-4999
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-06
Last Update Date:2012-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY802156981174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist