Provider Demographics
NPI:1447271432
Name:CAMERON, JACQUELINE R (MD)
Entity type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:R
Last Name:CAMERON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1290 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-4337
Mailing Address - Country:US
Mailing Address - Phone:312-498-8252
Mailing Address - Fax:
Practice Address - Street 1:164 OTROBANDO AVE
Practice Address - Street 2:
Practice Address - City:NORWICH
Practice Address - State:CT
Practice Address - Zip Code:06360-2116
Practice Address - Country:US
Practice Address - Phone:860-425-8740
Practice Address - Fax:860-886-1445
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-094554207R00000X
IL036094554207RH0002X
CT71961207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILG64723Medicare UPIN
ILK12476Medicare ID - Type UnspecifiedLAKE COUNTY
ILG64723Medicare UPIN