Provider Demographics
NPI:1700870193
Name:DE JESUS, STEPHANIE (MD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:DE JESUS
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 1:2060 E 61ST ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234-5908
Mailing Address - Country:US
Mailing Address - Phone:347-254-6462
Mailing Address - Fax:718-306-5238
Practice Address - Street 1:1501 N AMBURN RD STE 9
Practice Address - Street 2:
Practice Address - City:TEXAS CITY
Practice Address - State:TX
Practice Address - Zip Code:77591-2466
Practice Address - Country:US
Practice Address - Phone:281-218-7200
Practice Address - Fax:281-218-7203
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-31
Last Update Date:2020-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXTEXASRULE172.20207R00000X
NY1724301207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01169818Medicaid
NY1144361163OtherMEDICARE NPI ORGANIZATION
NY1144361163OtherMEDICARE NPI FO ORGANIZATION
NY01169818Medicaid
NY1144361163OtherMEDICARE NPI ORGANIZATION