Provider Demographics
NPI:1396768388
Name:JELLETT, CAROL (MD)
Entity type:Individual
Prefix:DR
First Name:CAROL
Middle Name:
Last Name:JELLETT
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 1:11 CRUM ELBOW ROAD
Mailing Address - Street 2:
Mailing Address - City:HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 CRUM ELBOW ROAD
Practice Address - Street 2:
Practice Address - City:HYDE PARK
Practice Address - State:NY
Practice Address - Zip Code:12538
Practice Address - Country:US
Practice Address - Phone:845-229-1020
Practice Address - Fax:845-229-2005
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2011-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY222115207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY312490OtherUSFHP (HMO)
NYH51875Medicare UPIN
NY38V861Medicare ID - Type Unspecified