Provider Demographics
NPI:1942245584
Name:VYAS, JAGDEEP (MD)
Entity type:Individual
Prefix:
First Name:JAGDEEP
Middle Name:
Last Name:VYAS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 ZECKENDORF BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:NY
Mailing Address - Zip Code:11530-2133
Mailing Address - Country:US
Mailing Address - Phone:516-542-6880
Mailing Address - Fax:516-542-5556
Practice Address - Street 1:350 S BROADWAY
Practice Address - Street 2:
Practice Address - City:HICKSVILLE
Practice Address - State:NY
Practice Address - Zip Code:11801-5006
Practice Address - Country:US
Practice Address - Phone:516-938-0100
Practice Address - Fax:516-938-0120
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-18
Last Update Date:2007-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227485207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYI01651Medicare UPIN
NY9255QTMedicare ID - Type Unspecified