Provider Demographics
NPI:1629023023
Name:PIERRE-JEROME SHOULTON, YARDLY (MD)
Entity Type:Individual
Prefix:
First Name:YARDLY
Middle Name:
Last Name:PIERRE-JEROME SHOULTON
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 1:2001 MARCUS AVE STE E249
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11042-1000
Mailing Address - Country:US
Mailing Address - Phone:516-437-5600
Mailing Address - Fax:516-437-7428
Practice Address - Street 1:13742 GUY R BREWER BLVD
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11434-3732
Practice Address - Country:US
Practice Address - Phone:718-977-1207
Practice Address - Fax:718-977-1256
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166834207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01839418Medicaid
NY9255ILMedicare ID - Type Unspecified