Provider Demographics
NPI:1952781353
Name:PARK AVENUE ENDOCRINOLOGY & NUTRITION PLLC
Entity Type:Organization
Organization Name:PARK AVENUE ENDOCRINOLOGY & NUTRITION PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CLIFTON
Authorized Official - Middle Name:
Authorized Official - Last Name:JACKNESS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:347-452-3571
Mailing Address - Street 1:103 E 75TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-2805
Mailing Address - Country:US
Mailing Address - Phone:212-772-7628
Mailing Address - Fax:
Practice Address - Street 1:103 E 75TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-2805
Practice Address - Country:US
Practice Address - Phone:212-772-7628
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-02
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty