Provider Demographics
NPI:1366540528
Name:JACOB, STANLEY (MD)
Entity type:Individual
Prefix:DR
First Name:STANLEY
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 1:147 PRIMROSE DR
Mailing Address - Street 2:
Mailing Address - City:NEW HYDE PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11040-2115
Mailing Address - Country:US
Mailing Address - Phone:718-490-1280
Mailing Address - Fax:
Practice Address - Street 1:180 PHILLIPS HILL RD
Practice Address - Street 2:SUITE 4A
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-4132
Practice Address - Country:US
Practice Address - Phone:845-499-2339
Practice Address - Fax:845-499-2340
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2011-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY241646208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics