Provider Demographics
NPI:1386969210
Name:WHITE, JACOB (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:WHITE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 32
Mailing Address - Street 2:
Mailing Address - City:NORTHBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60065-0032
Mailing Address - Country:US
Mailing Address - Phone:224-318-0118
Mailing Address - Fax:847-919-4615
Practice Address - Street 1:1264 SAINT NICHOLAS AVE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10033-7263
Practice Address - Country:US
Practice Address - Phone:347-532-1845
Practice Address - Fax:718-301-1099
Is Sole Proprietor?:No
Enumeration Date:2010-04-04
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY2648222085R0204X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04887023Medicaid