Provider Demographics
NPI:1821035262
Name:DERZIE, JACQUES A (MD)
Entity type:Individual
Prefix:DR
First Name:JACQUES
Middle Name:A
Last Name:DERZIE
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 1:1840 LAKEVILLE ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-1930
Mailing Address - Country:US
Mailing Address - Phone:516-354-1234
Mailing Address - Fax:516-354-6385
Practice Address - Street 1:1840 LAKEVILLE ROAD
Practice Address - Street 2:
Practice Address - City:NEW HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:11040-1930
Practice Address - Country:US
Practice Address - Phone:516-354-1234
Practice Address - Fax:516-354-6385
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2008-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
NY099934174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYD47468Medicare UPIN