Provider Demographics
NPI:1790179265
Name:PAUL, JESSY
Entity type:Individual
Prefix:
First Name:JESSY
Middle Name:
Last Name:PAUL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:794 KLONDIKE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-4824
Mailing Address - Country:US
Mailing Address - Phone:646-318-1760
Mailing Address - Fax:
Practice Address - Street 1:56 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06706-1253
Practice Address - Country:US
Practice Address - Phone:203-709-8820
Practice Address - Fax:203-709-3679
Is Sole Proprietor?:No
Enumeration Date:2015-03-23
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT54019207R00000X
NY291503207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine