Provider Demographics
NPI:1871580282
Name:TESORIERO, JACK JAMES (DC)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:JAMES
Last Name:TESORIERO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2103 DEER PARK AVE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729-1319
Mailing Address - Country:US
Mailing Address - Phone:631-242-4500
Mailing Address - Fax:631-242-0885
Practice Address - Street 1:2103 DEER PARK AVE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729-1319
Practice Address - Country:US
Practice Address - Phone:631-242-4500
Practice Address - Fax:631-242-0885
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX004766111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T52903Medicare UPIN
NYX26201Medicare PIN