Provider Demographics
NPI:1548250715
Name:ORFANOS, JACKIE P (MD)
Entity type:Individual
Prefix:
First Name:JACKIE
Middle Name:P
Last Name:ORFANOS
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 1:700 OLD COUNTRY RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803
Mailing Address - Country:US
Mailing Address - Phone:516-681-5801
Mailing Address - Fax:516-681-5861
Practice Address - Street 1:700 OLD COUNTRY RD
Practice Address - Street 2:SUITE 200
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803
Practice Address - Country:US
Practice Address - Phone:516-681-5801
Practice Address - Fax:516-681-5861
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-27
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY180070207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01429969Medicaid
13L172Medicare ID - Type Unspecified
NY01429969Medicaid