Provider Demographics
NPI:1528650066
Name:KORETZ, JESSE PHILLIP
Entity type:Individual
Prefix:DR
First Name:JESSE
Middle Name:PHILLIP
Last Name:KORETZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 BOULDEROL RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06903-1328
Mailing Address - Country:US
Mailing Address - Phone:203-536-4806
Mailing Address - Fax:
Practice Address - Street 1:1 GUSTAVE L LEVY PL # 1187
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-6504
Practice Address - Country:US
Practice Address - Phone:212-423-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program