Provider Demographics
NPI:1144380205
Name:JACOBS, MITCHEL (MD)
Entity Type:Individual
Prefix:
First Name:MITCHEL
Middle Name:
Last Name:JACOBS
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 1:891 NORTHERN BLVD
Mailing Address - Street 2:STE 203
Mailing Address - City:GREAT NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11021-5305
Mailing Address - Country:US
Mailing Address - Phone:516-773-6300
Mailing Address - Fax:516-706-4700
Practice Address - Street 1:891 NORTHERN BLVD
Practice Address - Street 2:SUITE 203
Practice Address - City:GREAT NECK
Practice Address - State:NY
Practice Address - Zip Code:11021-5334
Practice Address - Country:US
Practice Address - Phone:516-773-6300
Practice Address - Fax:516-796-4700
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2019-01-24
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY180855207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYE71555Medicare UPIN
WWQ641Medicare PIN