Basic Information
Provider Information | |||||||||
NPI: | 1396801031 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | BARRIENTOS | ||||||||
FirstName: | JACQUELINE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 410 LAKEVILLE RD STE 212 | ||||||||
Address2: |   | ||||||||
City: | NEW HYDE PARK | ||||||||
State: | NY | ||||||||
PostalCode: | 110421122 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5164704050 | ||||||||
FaxNumber: | 5164704250 | ||||||||
Practice Location | |||||||||
Address1: | 4306 ALTON RD FL 3 | ||||||||
Address2: |   | ||||||||
City: | MIAMI BEACH | ||||||||
State: | FL | ||||||||
PostalCode: | 331402840 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3055353310 | ||||||||
FaxNumber: | 3055353324 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/28/2006 | ||||||||
LastUpdateDate: | 03/14/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/14/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RH0003X | 238640 | NY | N |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology | 207RH0003X | ME154737 | FL | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Hematology & Oncology |
ID Information
ID | Type | State | Issuer | Description | BB9325146 | 01 | NY | DEA | OTHER | 238640 | 01 | NY | LICENSE | OTHER | 36036 | 01 | CT | CT CSR | OTHER | 043524 | 01 | CT | CT PHYSICIAN LICENSE | OTHER |