Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 208200000X | Surgeon | 219514 | NY |
Y | 208600000X | Surgeon | 219514 | NY |
NPI | 1023084779 |
---|---|
Provider Name | Brian Jacob |
First Address | New York, NY 10028-0130 |
Second Address | New York, NY 10028-0130 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/02/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
02588205 | (05) | NY |
I12897 | (02) |