Provider Demographics
NPI:1770550154
Name:JACOBS, EDWARD JULIUS (MD)
Entity type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:JULIUS
Last Name:JACOBS
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 1:62 HACKETT BLVD
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12209-1718
Mailing Address - Country:US
Mailing Address - Phone:518-465-7062
Mailing Address - Fax:518-449-1378
Practice Address - Street 1:62 HACKETT BLVD
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12209-1756
Practice Address - Country:US
Practice Address - Phone:518-465-7062
Practice Address - Fax:518-449-1378
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY129504207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00547764Medicaid
NY00547764Medicaid
NY38253BMedicare ID - Type Unspecified