Provider Demographics
NPI:1841677192
Name:JACOBY, ADAM (MD)
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:
Last Name:JACOBY
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:235 W END AVE
Mailing Address - Street 2:APARTMENT 16F
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10023-3631
Mailing Address - Country:US
Mailing Address - Phone:203-980-5245
Mailing Address - Fax:
Practice Address - Street 1:425 E 61ST ST FL 10
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10065-8722
Practice Address - Country:US
Practice Address - Phone:646-962-4250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-06
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT80024208200000X
390200000X
NY309895208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY309895OtherNEW YORK MEDICAL LICENSE
CT80024OtherCONNECTICUT MEDICAL LICENSE