Provider Demographics
NPI:1457350795
Name:NINIA, JERRY (MD)
Entity Type:Individual
Prefix:DR
First Name:JERRY
Middle Name:
Last Name:NINIA
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 1:4 ROOSEVELT AVE
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3363
Mailing Address - Country:US
Mailing Address - Phone:631-331-0500
Mailing Address - Fax:631-331-1644
Practice Address - Street 1:4 ROOSEVELT AVE
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3363
Practice Address - Country:US
Practice Address - Phone:631-331-0500
Practice Address - Fax:631-331-1644
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-19
Last Update Date:2017-04-27
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
NY174810207V00000X, 202K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No202K00000XAllopathic & Osteopathic PhysiciansPhlebology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE86317Medicare UPIN
NY80F171Medicare PIN