Healthcare Provider Details

I. General information

NPI: 1942417415
Provider Name (Legal Business Name): JACOB BORIS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

422 WESTERN HWY
TAPPAN NY
10983-1311
US

IV. Provider business mailing address

11 MORRIS RD
TAPPAN NY
10983-1603
US

V. Phone/Fax

Practice location:
  • Phone: 845-359-0010
  • Fax: 845-359-3414
Mailing address:
  • Phone: 845-359-6426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number088020
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: