Healthcare Provider Details

I. General information

NPI: 1720547821
Provider Name (Legal Business Name): JACOB ROTTER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2019
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 DEER PARK AVE
BABYLON NY
11702-1314
US

IV. Provider business mailing address

655 DEER PARK AVE
BABYLON NY
11702-1314
US

V. Phone/Fax

Practice location:
  • Phone: 631-321-2100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number315541-01
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2080P0206X
TaxonomyPediatric Gastroenterology Physician
License Number315541-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: