Healthcare Provider Details

I. General information

NPI: 1487706255
Provider Name (Legal Business Name): JACOB EISDORFER DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2007
Last Update Date: 07/19/2024
Certification Date: 07/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 LINDEN BLVD
BROOKLYN NY
11212-2438
US

IV. Provider business mailing address

1 BROOKDALE PLAZA PHYSICIAN ENTERPRISE SERVICES
BROOKLYN NY
11212
US

V. Phone/Fax

Practice location:
  • Phone: 718-240-7904
  • Fax: 718-240-7393
Mailing address:
  • Phone: 718-240-7904
  • Fax: 718-240-7393

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number25MB09093600
License Number StateNJ
# 2
Primary TaxonomyY
Taxonomy Code208C00000X
TaxonomyColon & Rectal Surgery Physician
License Number270778
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: