Provider Demographics
NPI:1942950589
Name:VANVORST, JACOB TYLER (DO)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:TYLER
Last Name:VANVORST
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 SADDLEBROOK LN
Mailing Address - Street 2:
Mailing Address - City:SCOTIA
Mailing Address - State:NY
Mailing Address - Zip Code:12302-9535
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34 MAPLE ST
Practice Address - Street 2:
Practice Address - City:NORWALK
Practice Address - State:CT
Practice Address - Zip Code:06850-3894
Practice Address - Country:US
Practice Address - Phone:203-852-2000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-26
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program