Basic Information
| Provider Information | |||||||||
| NPI: | 1073589602 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VIRGO | ||||||||
| FirstName: | JEFFERY | ||||||||
| MiddleName: | JASON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | OTC, OPA-C, RSA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 703 MALLARD WAY | ||||||||
| Address2: | |||||||||
| City: | PEEKSKILL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 105664178 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9147375608 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 234 E 149TH ST | ||||||||
| Address2: | |||||||||
| City: | BRONX | ||||||||
| State: | NY | ||||||||
| PostalCode: | 104515504 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7185795919 | ||||||||
| FaxNumber: | 7185794620 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/24/2006 | ||||||||
| LastUpdateDate: | 08/21/2008 | ||||||||
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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 | 174400000X | O000066-1 | NY | Y | Other Service Providers | Specialist | 246ZS0410X | N |
No ID Information.