Provider Demographics
NPI:1902898240
Name:HOM, JEFFREY (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:HOM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1559
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0989
Mailing Address - Country:US
Mailing Address - Phone:631-444-0650
Mailing Address - Fax:
Practice Address - Street 1:101 NICHOLLS ROAD
Practice Address - Street 2:STONY BROOK UNIVERSITY MEDICAL CENTER
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11790-0001
Practice Address - Country:US
Practice Address - Phone:631-444-0650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-22
Last Update Date:2015-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210776207P00000X, 207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG55969Medicare UPIN
NY376V71Medicare ID - Type Unspecified
NY02117164Medicaid