Provider Demographics
NPI:1720015746
Name:JACOB, REENA J (MD)
Entity Type:Individual
Prefix:
First Name:REENA
Middle Name:J
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:20 SQUADRON BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:NEW CITY
Mailing Address - State:NY
Mailing Address - Zip Code:10956-5200
Mailing Address - Country:US
Mailing Address - Phone:845-634-4567
Mailing Address - Fax:845-634-4564
Practice Address - Street 1:20 SQUADRON BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-5200
Practice Address - Country:US
Practice Address - Phone:845-634-4567
Practice Address - Fax:845-634-4564
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY218545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02148603Medicaid
NY02148603Medicaid
NYH34396Medicare UPIN