Provider Demographics
NPI:1487346227
Name:ARDITTI, JACOB MATTHEW
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:MATTHEW
Last Name:ARDITTI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 OLD TOWN RD
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-3452
Mailing Address - Country:US
Mailing Address - Phone:631-942-3942
Mailing Address - Fax:
Practice Address - Street 1:328 OLD TOWN RD
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-3452
Practice Address - Country:US
Practice Address - Phone:631-942-3942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-22
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant