Provider Demographics
NPI:1134368558
Name:JEROME A. CARIASO, M.D. PLLC
Entity type:Organization
Organization Name:JEROME A. CARIASO, M.D. PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:ABELLANA
Authorized Official - Last Name:CARIASO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-234-1112
Mailing Address - Street 1:2311 ADAM CLAYTON POWELL JR BLVD
Mailing Address - Street 2:FRONT A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-2663
Mailing Address - Country:US
Mailing Address - Phone:212-234-1112
Mailing Address - Fax:212-234-1997
Practice Address - Street 1:2311 ADAM CLAYTON POWELL JR BLVD
Practice Address - Street 2:FRONT A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-2663
Practice Address - Country:US
Practice Address - Phone:212-234-1112
Practice Address - Fax:212-234-1997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-09
Last Update Date:2009-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215615208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03070826Medicaid