Provider Demographics
NPI:1235326638
Name:FRED I. JACOBS DPM
Entity Type:Organization
Organization Name:FRED I. JACOBS DPM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF PODIATRIC MEDICINE
Authorized Official - Prefix:DR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:I
Authorized Official - Last Name:JACOBS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:518-587-7611
Mailing Address - Street 1:2 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:12833-1617
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7 WELLS ST
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-1200
Practice Address - Country:US
Practice Address - Phone:518-587-7611
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-29
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN2814332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00593935Medicaid
NYT26555Medicare UPIN
NY38621BMedicare PIN