Provider Demographics
NPI:1003914987
Name:MOALEM, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:MOALEM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE
Mailing Address - Street 2:BOX SURG
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-1611
Mailing Address - Fax:585-273-1252
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:BOX SURG
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642-0001
Practice Address - Country:US
Practice Address - Phone:585-275-1611
Practice Address - Fax:585-273-1252
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2023-07-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY2503862086X0206X
CAA982172086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY030355527Medicaid
NYJ400000447Medicare PIN