Provider Demographics
NPI:1932235603
Name:JAIN, JYOTSNA (OD)
Entity Type:Individual
Prefix:DR
First Name:JYOTSNA
Middle Name:
Last Name:JAIN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2260 VICTORY BLVD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6622
Mailing Address - Country:US
Mailing Address - Phone:718-448-1622
Mailing Address - Fax:718-448-7906
Practice Address - Street 1:2260 VICTORY BLVD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6622
Practice Address - Country:US
Practice Address - Phone:718-448-1622
Practice Address - Fax:718-448-7906
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV-005604-1152W00000X
NYVUT005604-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYVUTOO5604-1OtherLICENCE NUMBER NY
NY01525364Medicaid
NYC65171Medicare ID - Type Unspecified
NY01525364Medicaid