Provider Demographics
NPI:1710078787
Name:SAMANDER, JACOB A
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:A
Last Name:SAMANDER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5265 UNIVERSITY PKWY UNIT 101
Mailing Address - Street 2:
Mailing Address - City:UNIVERSITY PARK
Mailing Address - State:FL
Mailing Address - Zip Code:34201-3012
Mailing Address - Country:US
Mailing Address - Phone:914-941-1263
Mailing Address - Fax:
Practice Address - Street 1:165 MAIN ST
Practice Address - Street 2:
Practice Address - City:OSSINING
Practice Address - State:NY
Practice Address - Zip Code:10562-4702
Practice Address - Country:US
Practice Address - Phone:914-941-1263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME63339174400000X
CT443822084P0800X
NY241562-012084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04179026Medicaid
NY04179026Medicaid
DCG11395Medicare UPIN