Healthcare Provider Details

I. General information

NPI: 1952988024
Provider Name (Legal Business Name): NEIL JACOB MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2021
Last Update Date: 03/30/2021
Certification Date: 03/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1428 MADISON AVE BLDG 1
NEW YORK NY
10029-6508
US

IV. Provider business mailing address

1 GUSTAVE L LEVY PL # 1497
NEW YORK NY
10029-6504
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-6947
  • Fax: 212-860-3316
Mailing address:
  • Phone: 212-241-3688
  • Fax: 646-537-9405

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: