Provider Demographics
NPI:1831149731
Name:VARGHESE, JESSIE (MD)
Entity type:Individual
Prefix:DR
First Name:JESSIE
Middle Name:
Last Name:VARGHESE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:JESSIE
Other - Middle Name:
Other - Last Name:V PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 LUCILLE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-3414
Mailing Address - Country:US
Mailing Address - Phone:917-651-6022
Mailing Address - Fax:
Practice Address - Street 1:1572 NEW YORK AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON STATION
Practice Address - State:NY
Practice Address - Zip Code:11746-2418
Practice Address - Country:US
Practice Address - Phone:631-425-5250
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2025-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042047207R00000X
NY231327207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT010042047CT02OtherBCBS
NYQ37945Medicare UPIN