Provider Demographics
NPI:1811096506
Name:COSME, JACQUELINE
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:COSME
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 1:220 RIVERSIDE BLVD
Mailing Address - Street 2:APT. 18D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10069-1001
Mailing Address - Country:US
Mailing Address - Phone:212-860-0582
Mailing Address - Fax:
Practice Address - Street 1:390 W END AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10024-6107
Practice Address - Country:US
Practice Address - Phone:212-787-1444
Practice Address - Fax:212-799-8620
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1850902080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG29527Medicare UPIN