Provider Demographics
NPI:1902369754
Name:SUPERDOCK, JEFFREY EVAN (RN)
Entity Type:Individual
Prefix:MR
First Name:JEFFREY
Middle Name:EVAN
Last Name:SUPERDOCK
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 SYLVAN RD
Mailing Address - Street 2:
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-4926
Mailing Address - Country:US
Mailing Address - Phone:631-235-4068
Mailing Address - Fax:
Practice Address - Street 1:7 SYLVAN RD
Practice Address - Street 2:
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-4926
Practice Address - Country:US
Practice Address - Phone:631-235-4068
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2019-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY676260163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse