Provider Demographics
NPI:1336181866
Name:COLAH, JESSY (MD)
Entity type:Individual
Prefix:
First Name:JESSY
Middle Name:
Last Name:COLAH
Suffix:
Gender:M
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:PO BOX 161
Mailing Address - Street 2:
Mailing Address - City:BALDWIN
Mailing Address - State:NY
Mailing Address - Zip Code:11510-0161
Mailing Address - Country:US
Mailing Address - Phone:718-753-4585
Mailing Address - Fax:718-540-6243
Practice Address - Street 1:812 BONNIE DR
Practice Address - Street 2:
Practice Address - City:BALDWIN
Practice Address - State:NY
Practice Address - Zip Code:11510-4521
Practice Address - Country:US
Practice Address - Phone:718-753-4585
Practice Address - Fax:718-540-6243
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1676662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01889990Medicaid
NY01889990Medicaid
NY28E641Medicare PIN