Provider Demographics
NPI:1518073915
Name:TRACHTENBERG, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:TRACHTENBERG
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:PO BOX 478
Mailing Address - Street 2:
Mailing Address - City:VILLANOVA
Mailing Address - State:PA
Mailing Address - Zip Code:19085-0478
Mailing Address - Country:US
Mailing Address - Phone:610-527-0511
Mailing Address - Fax:610-270-2308
Practice Address - Street 1:559 W GERMANTOWN PIKE
Practice Address - Street 2:
Practice Address - City:NORRISTOWN
Practice Address - State:PA
Practice Address - Zip Code:19403-4250
Practice Address - Country:US
Practice Address - Phone:484-622-1695
Practice Address - Fax:484-622-4259
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2019-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD014012E2084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA098303001Medicaid
PA098303001Medicaid
B39834Medicare UPIN