Provider Demographics
NPI:1538150230
Name:MONACO-BAVARO, JACQUELINE (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:
Last Name:MONACO-BAVARO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10601-2214
Mailing Address - Country:US
Mailing Address - Phone:914-328-8444
Mailing Address - Fax:914-428-7696
Practice Address - Street 1:15 N BROADWAY
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10601-2214
Practice Address - Country:US
Practice Address - Phone:914-328-8444
Practice Address - Fax:914-428-7696
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY201602207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY016868821Medicaid
NY43G391Medicare ID - Type Unspecified
NY016868821Medicaid
NYG-54697Medicare UPIN