Provider Demographics
NPI:1891784021
Name:JACOBY, MEL S (MD)
Entity Type:Individual
Prefix:DR
First Name:MEL
Middle Name:S
Last Name:JACOBY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2263 S CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14618-2623
Mailing Address - Country:US
Mailing Address - Phone:585-241-6400
Mailing Address - Fax:585-241-6505
Practice Address - Street 1:1555 LONG POND RD
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14626-4122
Practice Address - Country:US
Practice Address - Phone:585-241-6400
Practice Address - Fax:585-241-6505
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2009-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1041852085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01196767Medicaid
NYE42865Medicare UPIN
NY01196767Medicaid