MEDICARE: KETZELA JACOBOWITZ MARSH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RI0200X	Infectious Disease Physician	62906	MN
2	2080P0208X	Pediatric Infectious Diseases Physician	62906	MN

General Provider Information

NPI Number	:	1568789006
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KETZELA JACOBOWITZ MARSH MD

Provider Business Mailing Address
First Line	:	410 LAKEVILLE RD STE 300
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11042-1123
Country	:	US
Telephone Number	:	718-470-3480
Fax Number	:

Provider Business Practice Location Address
First Line	:	410 LAKEVILLE RD STE 300
Second Line	:
City	:	NEW HYDE PARK
State	:	NY
Zip	:	11042-1123
Country	:	US
Telephone Number	:	718-470-3480
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/23/2010
Last Update Date	:	10/04/2023

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