Basic Information
| Provider Information | |||||||||
| NPI: | 1386997930 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JARAVAZA | ||||||||
| FirstName: | MUKAI | ||||||||
| MiddleName: | HEATHER | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | JARAVAZA | ||||||||
| OtherFirstName: | MUKAI | ||||||||
| OtherMiddleName: | HEATHER | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | M.D | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2570 ROUTE 9W | ||||||||
| Address2: | SUITE 10 | ||||||||
| City: | CORNWALL | ||||||||
| State: | NY | ||||||||
| PostalCode: | 125181323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8452203100 | ||||||||
| FaxNumber: | 8455342940 | ||||||||
| Practice Location | |||||||||
| Address1: | 147 LAKE STREET | ||||||||
| Address2: | GREATER HUDSON VALLEY FAMILY HEALTH CENT | ||||||||
| City: | NEWBURGH | ||||||||
| State: | NY | ||||||||
| PostalCode: | 12550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8455638000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2012 | ||||||||
| LastUpdateDate: | 11/21/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 267143 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.