Provider Demographics
NPI:1295902468
Name:JESUS PICHARDO MD PC
Entity type:Organization
Organization Name:JESUS PICHARDO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PEDIATRIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JESUS
Authorized Official - Middle Name:MANUEL
Authorized Official - Last Name:PICHARDO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-456-4600
Mailing Address - Street 1:1623 WEIRFIELD STREET
Mailing Address - Street 2:
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11385
Mailing Address - Country:US
Mailing Address - Phone:718-456-4600
Mailing Address - Fax:718-418-3549
Practice Address - Street 1:1623 WEIRFIELD ST
Practice Address - Street 2:
Practice Address - City:RIDGEWOOD
Practice Address - State:NY
Practice Address - Zip Code:11385-5349
Practice Address - Country:US
Practice Address - Phone:718-456-4600
Practice Address - Fax:718-418-3549
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-15
Last Update Date:2013-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY188066261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01463212Medicaid