Provider Demographics
NPI:1295754216
Name:AVIN, JACQUELINE (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:
Last Name:AVIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1068 ROXBURY DR
Mailing Address - Street 2:
Mailing Address - City:WESTBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11590-5422
Mailing Address - Country:US
Mailing Address - Phone:516-333-9313
Mailing Address - Fax:212-678-8461
Practice Address - Street 1:3170 BROADWAY
Practice Address - Street 2:GRANT HOUSES HEALTH CENTER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10027-3341
Practice Address - Country:US
Practice Address - Phone:212-678-8420
Practice Address - Fax:212-678-8461
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY157314208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01117835Medicaid
NY01117835Medicaid
NYD917760Medicare UPIN