Provider Demographics
NPI:1598329542
Name:RELIS, JAKE TAYLOR (DPM)
Entity Type:Individual
Prefix:DR
First Name:JAKE
Middle Name:TAYLOR
Last Name:RELIS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1165 NORTHERN BLVD STE 301
Mailing Address - Street 2:
Mailing Address - City:MANHASSET
Mailing Address - State:NY
Mailing Address - Zip Code:11030-3048
Mailing Address - Country:US
Mailing Address - Phone:516-365-4545
Mailing Address - Fax:
Practice Address - Street 1:1165 NORTHERN BLVD STE 301
Practice Address - Street 2:
Practice Address - City:MANHASSET
Practice Address - State:NY
Practice Address - Zip Code:11030-3048
Practice Address - Country:US
Practice Address - Phone:516-365-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-25
Last Update Date:2022-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN007262213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery