Provider Demographics
NPI:1205928124
Name:JESSURUN-SOLOMOU, JOSE (MD)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:
Last Name:JESSURUN-SOLOMOU
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 1:525 E 68TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10065-4870
Mailing Address - Country:US
Mailing Address - Phone:212-746-6481
Mailing Address - Fax:212-746-6484
Practice Address - Street 1:525 E 68TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-4870
Practice Address - Country:US
Practice Address - Phone:212-746-6481
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266154-1207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN082727OtherFAIRIVEW
MN101360OtherU CARE
768180OtherARAZ
MNHP22292OtherHEALTH PARTNERS
MN661388800Medicaid
MT0038590Medicaid
MN11-00014OtherMEDICA-PRIMARY
MN4T513JEOtherBLUE CROSS BLUE SHIELD
MN1010329OtherPREFERRED ONE
MN1124548OtherMEDICA-CHOICE