Provider Demographics
NPI:1174753743
Name:BRATHWAITE, JILLENE MYRNELLE (DO)
Entity type:Individual
Prefix:
First Name:JILLENE
Middle Name:MYRNELLE
Last Name:BRATHWAITE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:NY
Mailing Address - Zip Code:13790-2580
Mailing Address - Country:US
Mailing Address - Phone:607-729-8156
Mailing Address - Fax:
Practice Address - Street 1:40 ARCH ST
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:NY
Practice Address - Zip Code:13790-2102
Practice Address - Country:US
Practice Address - Phone:607-763-6092
Practice Address - Fax:607-763-6677
Is Sole Proprietor?:No
Enumeration Date:2009-07-17
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY254046207R00000X, 208M00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03128012Medicaid