Basic Information
Provider Information | |||||||||
NPI: | 1750619581 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | JASON HALEGOUA, M.D., P.C. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | PEDS FIRST PEDIATRICS | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3241 ROUTE 112 | ||||||||
Address2: | SUITE 7 | ||||||||
City: | MEDFORD | ||||||||
State: | NY | ||||||||
PostalCode: | 117631434 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6317325222 | ||||||||
FaxNumber: | 6317326222 | ||||||||
Practice Location | |||||||||
Address1: | 3241 ROUTE 112 | ||||||||
Address2: | SUITE 7 | ||||||||
City: | MEDFORD | ||||||||
State: | NY | ||||||||
PostalCode: | 117631434 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6317325222 | ||||||||
FaxNumber: | 6317326222 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/07/2009 | ||||||||
LastUpdateDate: | 01/07/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | HALEGOUA | ||||||||
AuthorizedOfficialFirstName: | JASON | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 6317325222 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD, MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 231789 | NY | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |   |
No ID Information.