Basic Information
Provider Information | |||||||||
NPI: | 1144202979 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | JESSUP | ||||||||
FirstName: | TODD | ||||||||
MiddleName: | P | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 155 CRYSTAL RUN RD | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | NY | ||||||||
PostalCode: | 109414028 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8457036999 | ||||||||
FaxNumber: | 8457036297 | ||||||||
Practice Location | |||||||||
Address1: | 61 EMERALD PL | ||||||||
Address2: |   | ||||||||
City: | ROCK HILL | ||||||||
State: | NY | ||||||||
PostalCode: | 127756049 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8457946999 | ||||||||
FaxNumber: | 8457036297 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/17/2005 | ||||||||
LastUpdateDate: | 09/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | 235870 | NY | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
ID | Type | State | Issuer | Description | 02675730 | 05 | NY |   | MEDICAID |