Provider Demographics
NPI:1851327308
Name:JACOBY, LAURIAN (MD)
Entity Type:Individual
Prefix:
First Name:LAURIAN
Middle Name:
Last Name:JACOBY
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 1:895 CHERRY LN
Mailing Address - Street 2:
Mailing Address - City:N WOODMERE
Mailing Address - State:NY
Mailing Address - Zip Code:11581-2722
Mailing Address - Country:US
Mailing Address - Phone:718-621-0336
Mailing Address - Fax:718-621-0339
Practice Address - Street 1:2281 82ND ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11214-2603
Practice Address - Country:US
Practice Address - Phone:718-621-0336
Practice Address - Fax:718-621-0339
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166878208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY12E342OtherMEDICARE
NY01043970Medicaid
NY12E342OtherMEDICARE