Healthcare Provider Details

I. General information

NPI: 1184422206
Provider Name (Legal Business Name): JACOB SAXON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/05/2025
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1776 BROADWAY STE 1410
NEW YORK NY
10019-2007
US

IV. Provider business mailing address

PO BOX 705
LAKE HARMONY PA
18624-0705
US

V. Phone/Fax

Practice location:
  • Phone: 212-877-7188
  • Fax:
Mailing address:
  • Phone: 570-855-4875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number011141
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: