Provider Demographics
NPI:1790778264
Name:EMMANUEL, JACQUELIN (MD)
Entity Type:Individual
Prefix:
First Name:JACQUELIN
Middle Name:
Last Name:EMMANUEL
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 1:8432 MIDLAND PKWY
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-2219
Mailing Address - Country:US
Mailing Address - Phone:718-658-7116
Mailing Address - Fax:212-828-7800
Practice Address - Street 1:75 E 116TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-1150
Practice Address - Country:US
Practice Address - Phone:212-828-7700
Practice Address - Fax:212-828-7800
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY135799207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01073192Medicaid
56D263Medicare ID - Type Unspecified
NY01073192Medicaid