Provider Demographics
NPI:1790726982
Name:JAN, DOMINIQUE M (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIQUE
Middle Name:M
Last Name:JAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 BAINBRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10467-2801
Mailing Address - Country:US
Mailing Address - Phone:718-920-7200
Mailing Address - Fax:718-547-2929
Practice Address - Street 1:3355 BAINBRIDGE AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2801
Practice Address - Country:US
Practice Address - Phone:718-920-7200
Practice Address - Fax:718-547-2929
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0024381204F00000X
NY2501822086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02729091Medicaid
NY517H21Medicare ID - Type Unspecified
NY02729091Medicaid