Provider Demographics
NPI:1730317868
Name:PHILLIPS, JACOB W (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:W
Last Name:PHILLIPS
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:PO BOX 505
Mailing Address - Street 2:
Mailing Address - City:NORTH CHILI
Mailing Address - State:NY
Mailing Address - Zip Code:14514-0505
Mailing Address - Country:US
Mailing Address - Phone:585-594-5995
Mailing Address - Fax:585-594-5425
Practice Address - Street 1:4201 BUFFALO ROAD, SUITE 1
Practice Address - Street 2:
Practice Address - City:NORTH CHILI
Practice Address - State:NY
Practice Address - Zip Code:14514-1256
Practice Address - Country:US
Practice Address - Phone:585-594-5995
Practice Address - Fax:585-594-5425
Is Sole Proprietor?:No
Enumeration Date:2009-06-26
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY320916208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice