Provider Demographics
NPI:1609138247
Name:SEDAGHATI, JENNIFER RAQUEL (OD)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:RAQUEL
Last Name:SEDAGHATI
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 EDGEWOOD PLACE
Mailing Address - Street 2:
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11024
Mailing Address - Country:US
Mailing Address - Phone:516-884-2316
Mailing Address - Fax:
Practice Address - Street 1:45 MAIN STREET
Practice Address - Street 2:
Practice Address - City:HASTINGS ON HUDSON
Practice Address - State:NY
Practice Address - Zip Code:10706
Practice Address - Country:US
Practice Address - Phone:914-478-0550
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-11
Last Update Date:2012-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007826152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist