Provider Demographics
NPI:1285811232
Name:DEJEAN, NINOUTCHKA (MD)
Entity type:Individual
Prefix:DR
First Name:NINOUTCHKA
Middle Name:
Last Name:DEJEAN
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 1:1601 CLINT MOORE RD
Mailing Address - Street 2:
Mailing Address - City:BOCA RATON
Mailing Address - State:FL
Mailing Address - Zip Code:33487-2768
Mailing Address - Country:US
Mailing Address - Phone:561-939-0520
Mailing Address - Fax:
Practice Address - Street 1:1601 CLINT MOORE RD
Practice Address - Street 2:
Practice Address - City:BOCA RATON
Practice Address - State:FL
Practice Address - Zip Code:33487-2768
Practice Address - Country:US
Practice Address - Phone:561-939-0520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-22
Last Update Date:2013-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246903207V00000X
FLME 106271207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL004717400Medicaid
FLEY743ZMedicare PIN