Provider Demographics
NPI:1912311960
Name:ENJ MEDICAL PC
Entity Type:Organization
Organization Name:ENJ MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:MARTIN
Authorized Official - Last Name:JACOBSON
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:347-262-2427
Mailing Address - Street 1:206 AVERY PL
Mailing Address - Street 2:
Mailing Address - City:CEDARHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11516-1805
Mailing Address - Country:US
Mailing Address - Phone:347-262-2427
Mailing Address - Fax:516-400-9309
Practice Address - Street 1:275 ROCKAWAY TPKE
Practice Address - Street 2:SUITE A
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1272
Practice Address - Country:US
Practice Address - Phone:516-400-9302
Practice Address - Fax:516-400-9309
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-18
Last Update Date:2014-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY267245207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1306154703Medicare PIN