Healthcare Provider Details

I. General information

NPI: 1831178318
Provider Name (Legal Business Name): MARK I JACOBSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 10/29/2020
Certification Date: 10/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

560 WHITE PLAINS RD FL 6
TARRYTOWN NY
10591-5113
US

IV. Provider business mailing address

560 WHITE PLAINS RD FL 6
TARRYTOWN NY
10591-5113
US

V. Phone/Fax

Practice location:
  • Phone: 914-345-1100
  • Fax: 914-345-1101
Mailing address:
  • Phone: 914-345-1100
  • Fax: 914-345-1101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number173191-1
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License Number173191-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: