Provider Demographics
NPI:1326140336
Name:LIST, JACOB B (OD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:B
Last Name:LIST
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:2921 ERIE BLVD EAST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13224
Mailing Address - Country:US
Mailing Address - Phone:315-445-7465
Mailing Address - Fax:315-445-7675
Practice Address - Street 1:140 STATE ROUTE 104
Practice Address - Street 2:OSWEGO PLAZA EMPIRE VISION CENTERS
Practice Address - City:OSWEGO
Practice Address - State:NY
Practice Address - Zip Code:13126
Practice Address - Country:US
Practice Address - Phone:315-342-0727
Practice Address - Fax:315-342-3044
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV0070721152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRB2662Medicare PIN
NYRB2664Medicare PIN
NYRB2663Medicare PIN
NYRB2665Medicare PIN