Provider Demographics
NPI:1477699692
Name:JACOBSON, ERIC (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
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 1:3 OAK LEAF COURT
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:NY
Mailing Address - Zip Code:11743
Mailing Address - Country:US
Mailing Address - Phone:718-308-6189
Mailing Address - Fax:718-884-5002
Practice Address - Street 1:5822 BROADWAY
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10463-2454
Practice Address - Country:US
Practice Address - Phone:718-549-3185
Practice Address - Fax:718-884-5002
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2010-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY183866-1208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
2700367OtherGHI
2I2972OtherBLUE CROSS BLUE SHIELD
02012GMedicare ID - Type UnspecifiedINDIVIDUAL
02012Medicare ID - Type UnspecifiedGROUP
2I2972OtherBLUE CROSS BLUE SHIELD