Provider Demographics
NPI:1255772307
Name:POTHEN, JENNIFER (MD)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:POTHEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:VARGHESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:47 TOWN ST
Mailing Address - Street 2:
Mailing Address - City:NORWICH
Mailing Address - State:CT
Mailing Address - Zip Code:06360-2315
Mailing Address - Country:US
Mailing Address - Phone:860-892-7042
Mailing Address - Fax:
Practice Address - Street 1:1 DAKOTA DR STE 218
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11042-1136
Practice Address - Country:US
Practice Address - Phone:516-488-9700
Practice Address - Fax:516-488-8826
Is Sole Proprietor?:No
Enumeration Date:2013-07-17
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT52266207Q00000X
NY315296207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008046940Medicaid
NY07530096Medicaid