Provider Demographics
NPI:1427638063
Name:PERSILY, JESSE BENJAMIN (MD)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:BENJAMIN
Last Name:PERSILY
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 1:28 GRAVERSHAM
Mailing Address - Street 2:
Mailing Address - City:MARLBORO
Mailing Address - State:NJ
Mailing Address - Zip Code:07746-2726
Mailing Address - Country:US
Mailing Address - Phone:732-239-0455
Mailing Address - Fax:
Practice Address - Street 1:550 1ST AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-6402
Practice Address - Country:US
Practice Address - Phone:212-263-5506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program