Healthcare Provider Details

I. General information

NPI: 1407857634
Provider Name (Legal Business Name): JACOB K MATHEW MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 03/09/2026
Certification Date: 03/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

475 E MAIN ST STE 205
PATCHOGUE NY
11772-3121
US

IV. Provider business mailing address

100 OAKLAND AVE SUITE 4
PORT JEFFERSON NY
11777-2172
US

V. Phone/Fax

Practice location:
  • Phone: 631-394-2550
  • Fax: 631-654-1474
Mailing address:
  • Phone: 631-476-4780
  • Fax: 631-476-4781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number196027
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: