Provider Demographics
NPI:1710083050
Name:ACKERMAN, JACOB L (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:L
Last Name:ACKERMAN
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 1:1901 UTICA AVE
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11234
Mailing Address - Country:US
Mailing Address - Phone:718-968-8700
Mailing Address - Fax:718-968-8743
Practice Address - Street 1:1901 UTICA AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11234
Practice Address - Country:US
Practice Address - Phone:718-968-8700
Practice Address - Fax:718-968-8743
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2012-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY112574207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY180029308OtherRAILROAD MEDICARE
NY00203892Medicaid
NY0147830001OtherNHIC
NY5770100Medicare ID - Type Unspecified
NYB78015Medicare UPIN