Provider Demographics
NPI:1891168340
Name:JACOB, MAUD
Entity Type:Individual
Prefix:
First Name:MAUD
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13020 116TH AVE
Mailing Address - Street 2:
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11420-2622
Mailing Address - Country:US
Mailing Address - Phone:410-940-1529
Mailing Address - Fax:
Practice Address - Street 1:374 STOCKHOLM ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237-4006
Practice Address - Country:US
Practice Address - Phone:410-940-1529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-05
Last Update Date:2015-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYP99938208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery