Basic Information
| Provider Information | |||||||||
| NPI: | 1194935122 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DUBOW | ||||||||
| FirstName: | JORDAN | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 20 GRAND ST | ||||||||
| Address2: | CBO - 3RD FLOOR | ||||||||
| City: | WARWICK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109901035 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8459873973 | ||||||||
| FaxNumber: | 8459875979 | ||||||||
| Practice Location | |||||||||
| Address1: | 257 LAFAYETTE AVE | ||||||||
| Address2: | SUITE 330 | ||||||||
| City: | SUFFERN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 109014830 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8453688808 | ||||||||
| FaxNumber: | 8453685608 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 05/12/2010 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 036-118122 | IL | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology | 2084N0400X | 255345 | NY | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 255345 | 01 | NY | NY LICENSE # | OTHER | 036-118122 | 01 | IL | IL STATE LIC | OTHER |