Provider Demographics
NPI:1023084779
Name:JACOB, BRIAN (MD)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:JACOB
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 1:1010 5TH AVE
Mailing Address - Street 2:LAPAROSCOPIC SURGERY CENTER
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0130
Mailing Address - Country:US
Mailing Address - Phone:212-879-6677
Mailing Address - Fax:212-650-9981
Practice Address - Street 1:1010 5TH AVE
Practice Address - Street 2:LAPAROSCOPIC SURGICAL CENTER
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0130
Practice Address - Country:US
Practice Address - Phone:212-879-6677
Practice Address - Fax:212-650-9981
Is Sole Proprietor?:No
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY219514208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02588205Medicaid
NY02588205Medicaid
NY3181H1Medicare ID - Type Unspecified