Provider Demographics
NPI:1851390785
Name:HENTEL, JACOB I (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:I
Last Name:HENTEL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:JACK
Other - Middle Name:I
Other - Last Name:HENTEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1 COLUMBIA ST
Mailing Address - Street 2:DRA IMAGING, P.C.
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-3924
Mailing Address - Country:US
Mailing Address - Phone:845-454-4700
Mailing Address - Fax:845-454-4982
Practice Address - Street 1:1 COLUMBIA ST
Practice Address - Street 2:DRA IMAGING, P.C.
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-3923
Practice Address - Country:US
Practice Address - Phone:845-454-4700
Practice Address - Fax:845-454-4982
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2009-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1019112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00395102Medicaid
NYB78306Medicare UPIN
NY00395102Medicaid