Provider Demographics
NPI:1851749089
Name:JACOVETTY, ERICA LEIGH
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:LEIGH
Last Name:JACOVETTY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 SKYLINE DR
Mailing Address - Street 2:NEW YORK MEDICAL COLLEGE, DEPT OF OB/GYN
Mailing Address - City:HAWTHORN
Mailing Address - State:NY
Mailing Address - Zip Code:10532
Mailing Address - Country:US
Mailing Address - Phone:914-594-2112
Mailing Address - Fax:
Practice Address - Street 1:121 MEDICAL CENTER DR STE 2700
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2669
Practice Address - Country:US
Practice Address - Phone:207-721-8715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-27
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MEMD23897207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program