Provider Demographics
NPI:1629082730
Name:ROZBRUCH, JACOB D (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:D
Last Name:ROZBRUCH
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 1:420 E 72ND ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-4650
Mailing Address - Country:US
Mailing Address - Phone:212-744-9857
Mailing Address - Fax:212-988-9022
Practice Address - Street 1:420 E 72ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-4650
Practice Address - Country:US
Practice Address - Phone:212-744-9857
Practice Address - Fax:212-988-9022
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY120603174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA98109Medicare UPIN
NY05A631Medicare ID - Type Unspecified