Provider Demographics
NPI:1407857634
Name:MATHEW, JACOB K (MD)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:K
Last Name:MATHEW
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:100 OAKLAND AVE
Mailing Address - Street 2:SUITE 4
Mailing Address - City:PORT JEFFERSON
Mailing Address - State:NY
Mailing Address - Zip Code:11777-2172
Mailing Address - Country:US
Mailing Address - Phone:631-476-4780
Mailing Address - Fax:631-476-4781
Practice Address - Street 1:100 OAKLAND AVE
Practice Address - Street 2:SUITE 4
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-2172
Practice Address - Country:US
Practice Address - Phone:631-476-4780
Practice Address - Fax:631-476-4781
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1960272084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01494779Medicaid
NY01494779Medicaid
F82771Medicare UPIN