Provider Demographics
NPI:1194805929
Name:JAMAICA ESTATES FAMILY MEDICAL PC
Entity type:Organization
Organization Name:JAMAICA ESTATES FAMILY MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:EDGAR
Authorized Official - Middle Name:Z
Authorized Official - Last Name:VANEGAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-658-7482
Mailing Address - Street 1:8505 167TH ST
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11432-2621
Mailing Address - Country:US
Mailing Address - Phone:718-658-7482
Mailing Address - Fax:718-658-7531
Practice Address - Street 1:8505 167TH ST
Practice Address - Street 2:
Practice Address - City:JAMAICA
Practice Address - State:NY
Practice Address - Zip Code:11432-2621
Practice Address - Country:US
Practice Address - Phone:718-658-7482
Practice Address - Fax:718-658-7531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-16
Last Update Date:2013-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY190283-1207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02576630Medicaid
NY02576630Medicaid