Healthcare Provider Details

I. General information

NPI: 1386969210
Provider Name (Legal Business Name): JACOB WHITE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2010
Last Update Date: 11/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1264 SAINT NICHOLAS AVE
NEW YORK NY
10033-7263
US

IV. Provider business mailing address

PO BOX 32
NORTHBROOK IL
60065-0032
US

V. Phone/Fax

Practice location:
  • Phone: 347-532-1845
  • Fax: 718-301-1099
Mailing address:
  • Phone: 224-318-0118
  • Fax: 847-919-4615

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number264822
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: