Provider Demographics
NPI:1346388162
Name:JACOB, HARRY S (MD)
Entity Type:Individual
Prefix:
First Name:HARRY
Middle Name:S
Last Name:JACOB
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 1:18 COVERT STREET
Mailing Address - Street 2:
Mailing Address - City:PORT WASHINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11050
Mailing Address - Country:US
Mailing Address - Phone:631-454-4080
Mailing Address - Fax:631-454-4088
Practice Address - Street 1:2800 MARCUS AVENUE
Practice Address - Street 2:SUITE 203
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-354-7900
Practice Address - Fax:631-454-4088
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112426207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C07895Medicare UPIN
NY290281Medicare ID - Type Unspecified