Provider Demographics
NPI:1831311588
Name:JACOB, GLADY (MD)
Entity Type:Individual
Prefix:
First Name:GLADY
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
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 2000
Mailing Address - Street 2:
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-4500
Mailing Address - Country:US
Mailing Address - Phone:315-362-5129
Mailing Address - Fax:315-362-5179
Practice Address - Street 1:267 AVERY LN STE 300
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13441-4240
Practice Address - Country:US
Practice Address - Phone:315-356-7390
Practice Address - Fax:315-356-7393
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2023-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY003788-12084N0400X, 2084N0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084N0600XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyClinical Neurophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03351764Medicaid
J400048201Medicare UPIN