Provider Demographics
NPI:1700851375
Name:SKEZAS, JACOB WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:WILLIAM
Last Name:SKEZAS
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 1:1 GUTHRIE SQ
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:PA
Mailing Address - Zip Code:18840-1625
Mailing Address - Country:US
Mailing Address - Phone:570-888-5858
Mailing Address - Fax:
Practice Address - Street 1:1780 HANSHAW RD
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-9105
Practice Address - Country:US
Practice Address - Phone:607-257-5858
Practice Address - Fax:607-257-1718
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD038449E207R00000X
NY176831-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01088191Medicaid
PA0011242630002Medicaid
NYCC8362OtherRR MEDICARE GROUP
NY110079070OtherRR MEDICARE PIN
NY50606CMedicare PIN
NYCC8362OtherRR MEDICARE GROUP