Provider Demographics
NPI:1700382868
Name:ROSENBLUM, JAKE DYLAN (DO)
Entity Type:Individual
Prefix:
First Name:JAKE
Middle Name:DYLAN
Last Name:ROSENBLUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1171 OLD COUNTRY RD STE 5
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-5022
Mailing Address - Country:US
Mailing Address - Phone:516-938-7676
Mailing Address - Fax:
Practice Address - Street 1:1171 OLD COUNTRY RD STE 5
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-5022
Practice Address - Country:US
Practice Address - Phone:516-938-7676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-05
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY308789207RA0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0201XAllopathic & Osteopathic PhysiciansInternal MedicineAllergy & Immunology