Provider Demographics
NPI:1942417415
Name:BORIS, JACOB (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:BORIS
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 1:11 MORRIS RD
Mailing Address - Street 2:
Mailing Address - City:TAPPAN
Mailing Address - State:NY
Mailing Address - Zip Code:10983-1603
Mailing Address - Country:US
Mailing Address - Phone:845-359-6426
Mailing Address - Fax:
Practice Address - Street 1:422 WESTERN HWY
Practice Address - Street 2:
Practice Address - City:TAPPAN
Practice Address - State:NY
Practice Address - Zip Code:10983-1311
Practice Address - Country:US
Practice Address - Phone:845-359-0010
Practice Address - Fax:845-359-3414
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY088020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00530781Medicaid
NYB80081Medicare UPIN