Basic Information
| Provider Information | |||||||||
| NPI: | 1225076722 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IYPE | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2799 ROUTE 112 | ||||||||
| Address2: | SUITE #11 | ||||||||
| City: | MEDFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317325222 | ||||||||
| FaxNumber: | 6317326222 | ||||||||
| Practice Location | |||||||||
| Address1: | 2799 ROUTE 112 | ||||||||
| Address2: | SUITE #11 | ||||||||
| City: | MEDFORD | ||||||||
| State: | NY | ||||||||
| PostalCode: | 11763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6317325222 | ||||||||
| FaxNumber: | 6317326222 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2006 | ||||||||
| LastUpdateDate: | 05/16/2016 | ||||||||
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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 | 208000000X | 231749 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 7662603 | 01 | NY | AETNA | OTHER | 6B6671 | 01 | NY | EMPIRE BC.BS | OTHER | 02559680 | 05 | NY | MEDICAID |