Healthcare Provider Details

I. General information

NPI: 1396762191
Provider Name (Legal Business Name): JACOB KATANOV P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

540 ATLANTIC AVE
BROOKLYN NY
11217-1985
US

IV. Provider business mailing address

2202 STEINWAY ST
ASTORIA NY
11105-1836
US

V. Phone/Fax

Practice location:
  • Phone: 718-855-4900
  • Fax: 718-802-0631
Mailing address:
  • Phone: 718-423-0808
  • Fax: 718-204-6866

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number007935
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: