Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 124938 | NY |
N | 2080P0203X | Pediatric Critical Care Doctor | 124938 | NY |
NPI | 1083650949 |
---|---|
Provider Name | Dr. Elise W Van Der Jagt |
First Address | Rochester, NY 14642-0001 |
Second Address | Rochester, NY 14642-0001 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/06/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
00512863 | (05) | NY |
H33597 | (02) |