Provider Demographics
NPI:1386748416
Name:ABDUR R JALAZAI MD PC
Entity type:Organization
Organization Name:ABDUR R JALAZAI MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:ABDUR
Authorized Official - Middle Name:R
Authorized Official - Last Name:JALALZAI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:315-535-9229
Mailing Address - Street 1:63 WEST BARNEY ST
Mailing Address - Street 2:
Mailing Address - City:GOUVERNEUR
Mailing Address - State:NY
Mailing Address - Zip Code:13642
Mailing Address - Country:US
Mailing Address - Phone:315-287-1770
Mailing Address - Fax:315-287-1170
Practice Address - Street 1:63 WEST BARNEY ST
Practice Address - Street 2:
Practice Address - City:GOUVERNEUR
Practice Address - State:NY
Practice Address - Zip Code:13642
Practice Address - Country:US
Practice Address - Phone:315-287-1770
Practice Address - Fax:315-287-1170
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY126123207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00615623Medicaid
B81539Medicare UPIN
NY00615623Medicaid