Healthcare Provider Details

I. General information

NPI: 1154647451
Provider Name (Legal Business Name): TIKVA JACOBS MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/12/2010
Last Update Date: 04/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 5TH AVE
NEW YORK NY
10128-0143
US

IV. Provider business mailing address

1125 5TH AVE
NEW YORK NY
10128-0143
US

V. Phone/Fax

Practice location:
  • Phone: 212-288-9800
  • Fax: 212-860-7446
Mailing address:
  • Phone: 212-288-9800
  • Fax: 212-860-7446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number214917
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number214917
License Number StateNY

VIII. Authorized Official

Name: TIKVA JACOBS
Title or Position: MD
Credential: MD
Phone: 212-288-9800