Provider Demographics
NPI:1013192566
Name:LAWRENCE MARC JACOBSON MD PLLC
Entity Type:Organization
Organization Name:LAWRENCE MARC JACOBSON MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:M
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:212-981-9812
Mailing Address - Street 1:40 PARK AVE STE 4
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-3467
Mailing Address - Country:US
Mailing Address - Phone:212-981-9812
Mailing Address - Fax:
Practice Address - Street 1:40 PARK AVE STE 4
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3467
Practice Address - Country:US
Practice Address - Phone:212-981-9812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-03
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191576207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYW39571OtherMEDICARE PTAN
NY01618395Medicaid
NY2003139571OtherMEDICARE PTIN
NY01618395Medicaid
NYW39573OtherMEDICARE PIN
NYW39571OtherMEDICARE PTAN