Basic Information
| Provider Information | |||||||||
| NPI: | 1043278906 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VAVAL | ||||||||
| FirstName: | JEAN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 80 MARCUS DR | ||||||||
| Address2: | PROVIDER ENROLLMENT | ||||||||
| City: | MELVILLE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117474230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6313917887 | ||||||||
| FaxNumber: | 6314544163 | ||||||||
| Practice Location | |||||||||
| Address1: | 8900 VAN WYCK EXPRESSWAY | ||||||||
| Address2: | |||||||||
| City: | JAMAICA | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11418 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7182066088 | ||||||||
| FaxNumber: | 7182068087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/02/2006 | ||||||||
| LastUpdateDate: | 01/18/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | 163744 | NY | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 00911702 | 05 | NY | MEDICAID |