Provider Demographics
NPI:1457433666
Name:KACYRAT, JAMAL K (MD)
Entity Type:Individual
Prefix:
First Name:JAMAL
Middle Name:K
Last Name:KACYRAT
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 1:26 CONKEY AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:NORWICH
Mailing Address - State:NY
Mailing Address - Zip Code:13815
Mailing Address - Country:US
Mailing Address - Phone:607-334-5772
Mailing Address - Fax:607-334-1922
Practice Address - Street 1:26 CONKEY AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:NORWICH
Practice Address - State:NY
Practice Address - Zip Code:13815
Practice Address - Country:US
Practice Address - Phone:607-334-5772
Practice Address - Fax:607-334-1922
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155373208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00783160Medicaid
NY00783160Medicaid
NY39174BMedicare ID - Type Unspecified