Provider Demographics
NPI:1104053065
Name:KHURGIN, JACOB LEON (DO)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:LEON
Last Name:KHURGIN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 W 97TH ST
Mailing Address - Street 2:APT 5D
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-6472
Mailing Address - Country:US
Mailing Address - Phone:646-418-7853
Mailing Address - Fax:
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:718-283-7634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-18
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT013043390200000X
MDH0077362208800000X
NY279506208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program