Provider Demographics
NPI:1659333144
Name:MARIE JACQUELINE MOISES MD
Entity Type:Organization
Organization Name:MARIE JACQUELINE MOISES MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:MARIE
Authorized Official - Middle Name:JACQUELINE
Authorized Official - Last Name:MOISES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-740-3106
Mailing Address - Street 1:21517 JAMAICA AVE
Mailing Address - Street 2:
Mailing Address - City:QUEENS VILLAGE
Mailing Address - State:NY
Mailing Address - Zip Code:11428-1715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:21517 JAMAICA AVE
Practice Address - Street 2:
Practice Address - City:QUEENS VILLAGE
Practice Address - State:NY
Practice Address - Zip Code:11428-1715
Practice Address - Country:US
Practice Address - Phone:718-740-3106
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY151357173000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes173000000XOther Service ProvidersLegal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01163859Medicaid
NY01163859Medicaid