Provider Demographics
NPI:1811301799
Name:JACOB, MARIANN C (MD)
Entity type:Individual
Prefix:DR
First Name:MARIANN
Middle Name:C
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:432 ARGYLE RD
Mailing Address - Street 2:
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501-1014
Mailing Address - Country:US
Mailing Address - Phone:847-208-3277
Mailing Address - Fax:
Practice Address - Street 1:430 EAST 34TH STREET
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016
Practice Address - Country:US
Practice Address - Phone:866-733-7698
Practice Address - Fax:212-562-6019
Is Sole Proprietor?:No
Enumeration Date:2014-06-18
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI62609-20208000000X
IL036.35602208000000X
WI62609208M00000X
NY316056208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY07137497Medicaid
WI1811301799Medicaid