Provider Demographics
NPI:1699227058
Name:JACQUELINE F. NOBOA D.P.M.
Entity Type:Organization
Organization Name:JACQUELINE F. NOBOA D.P.M.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JACQUELINE
Authorized Official - Middle Name:F
Authorized Official - Last Name:NOBOA
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:718-548-1988
Mailing Address - Street 1:3898 SEDGWICK AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10463-4423
Mailing Address - Country:US
Mailing Address - Phone:718-548-1988
Mailing Address - Fax:
Practice Address - Street 1:3898 SEDGWICK AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-4423
Practice Address - Country:US
Practice Address - Phone:718-548-1988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-11-01
Last Update Date:2016-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN004510213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY480015944OtherPALMETTO GBA RAILROAD MCARE
NY0021631OtherGHI
NY000592413OtherAPWU
NY01132636Medicaid
NYP787330Other0XFORD
NY01132636Medicaid
NYT82991Medicare UPIN