Provider Demographics
NPI:1902868292
Name:LASTIG, JESSICA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:LYNN
Last Name:LASTIG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JESSICA
Other - Middle Name:LYNN
Other - Last Name:CHIMON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:935 NORTHERN BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5309
Mailing Address - Country:US
Mailing Address - Phone:516-829-4414
Mailing Address - Fax:516-829-5286
Practice Address - Street 1:935 NORTHERN BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5309
Practice Address - Country:US
Practice Address - Phone:516-829-4414
Practice Address - Fax:516-829-5286
Is Sole Proprietor?:No
Enumeration Date:2006-04-04
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1770332085B0100X, 2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085B0100XAllopathic & Osteopathic PhysiciansRadiologyBody Imaging
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01344283Medicaid
NY01344283Medicaid
NYF33198Medicare UPIN