Provider Demographics
NPI:1013984392
Name:BURACK, JEDIDIAH (MD)
Entity Type:Individual
Prefix:DR
First Name:JEDIDIAH
Middle Name:
Last Name:BURACK
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 1:55 GREENE AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11238-6406
Mailing Address - Country:US
Mailing Address - Phone:718-789-5900
Mailing Address - Fax:718-233-3318
Practice Address - Street 1:55 GREENE AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11238-6406
Practice Address - Country:US
Practice Address - Phone:718-789-5900
Practice Address - Fax:718-233-3318
Is Sole Proprietor?:No
Enumeration Date:2006-03-04
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190896207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01497350Medicaid
02J49Medicare ID - Type Unspecified
02J49Medicare PIN
NY01497350Medicaid