Provider Demographics
NPI:1366442113
Name:JACOB, MAHIMA (MD)
Entity Type:Individual
Prefix:
First Name:MAHIMA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:69 S BROADWAY
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-4004
Mailing Address - Country:US
Mailing Address - Phone:914-376-5555
Mailing Address - Fax:914-964-1477
Practice Address - Street 1:69 S BROADWAY
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-4004
Practice Address - Country:US
Practice Address - Phone:914-376-5555
Practice Address - Fax:914-964-1477
Is Sole Proprietor?:No
Enumeration Date:2005-07-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY230656207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02619776Medicaid
NY02619776Medicaid
NY257AR1Medicare ID - Type Unspecified