Provider Demographics
NPI:1316044563
Name:JACOBSON, MICHAEL (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 E END AVE APT 6B
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10075-1153
Mailing Address - Country:US
Mailing Address - Phone:646-238-0560
Mailing Address - Fax:646-619-4711
Practice Address - Street 1:2 E END AVE APT 6B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10075-1153
Practice Address - Country:US
Practice Address - Phone:646-238-0560
Practice Address - Fax:646-619-4711
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2023-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY163279207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
00E141Medicare ID - Type Unspecified
A59844Medicare UPIN