Provider Demographics
NPI:1386795664
Name:KORNGOLD, JAY MITCHELL (MD)
Entity type:Individual
Prefix:DR
First Name:JAY
Middle Name:MITCHELL
Last Name:KORNGOLD
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 1:125 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-3501
Mailing Address - Country:US
Mailing Address - Phone:845-634-4554
Mailing Address - Fax:845-639-1959
Practice Address - Street 1:125 S MAIN ST
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-3501
Practice Address - Country:US
Practice Address - Phone:845-634-4554
Practice Address - Fax:845-639-1959
Is Sole Proprietor?:No
Enumeration Date:2007-01-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222599-1174400000X
NJ25MA07711400174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH82629Medicare UPIN
NY1212F1Medicare ID - Type Unspecified
NJ089133TOZMedicare ID - Type Unspecified