Healthcare Provider Details

I. General information

NPI: 1811225394
Provider Name (Legal Business Name): DAVID T JACOBS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/22/2009
Last Update Date: 09/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 MAPLE AVE STE 2
ROCKVILLE CENTRE NY
11570-4259
US

IV. Provider business mailing address

316 EDWARD AVE
WOODMERE NY
11598-2823
US

V. Phone/Fax

Practice location:
  • Phone: 516-865-1234
  • Fax:
Mailing address:
  • Phone: 646-831-2744
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberXXXXXXX
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number257302
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number257302
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number257302
License Number StateNY
# 5
Primary TaxonomyY
Taxonomy Code202K00000X
TaxonomyPhlebology Physician
License Number257302
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: