Provider Demographics
NPI:1679594675
Name:LEVY, JACOB DANIEL (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:DANIEL
Last Name:LEVY
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 1:2665 N DECATUR RD
Mailing Address - Street 2:SUITE 260
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30033-6149
Mailing Address - Country:US
Mailing Address - Phone:404-297-9077
Mailing Address - Fax:404-296-1220
Practice Address - Street 1:1011 BOWLES AVE
Practice Address - Street 2:SUITE 300
Practice Address - City:RICHMOND HEIGHTS
Practice Address - State:MO
Practice Address - Zip Code:63117
Practice Address - Country:US
Practice Address - Phone:636-496-5048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-22
Last Update Date:2023-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2264571207RC0000X
MDD84453207RC0000X
TXR6432207RC0000X
OK32799207RC0000X
KS04-41155207RC0000X
IN01079565A207RC0000X
WI68773207RC0000X
FLME133455207RC0000X
VA0101263074207RC0000X
IL036145353207RC0000X
GA057393207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
0-570-912-6OtherECFMG
GA057393OtherGA STATE LICENSE
NY2264571OtherNY STATE LICENSE
BL8118211OtherDEA LICENSE
NY2264571OtherNY STATE LICENSE
GA11SCGNCMedicare PIN
GA057393OtherGA STATE LICENSE