Provider Demographics
NPI:1427132034
Name:PISKUN, JACOB (MD)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:PISKUN
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 1:14 WHITEWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TENAFLY
Mailing Address - State:NJ
Mailing Address - Zip Code:07670-3020
Mailing Address - Country:US
Mailing Address - Phone:718-815-1000
Mailing Address - Fax:718-815-8122
Practice Address - Street 1:195 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2957
Practice Address - Country:US
Practice Address - Phone:631-385-8677
Practice Address - Fax:718-815-8122
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY215745-1174400000X
NY215745207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ049137Medicare ID - Type Unspecified
NY7L7701Medicare ID - Type Unspecified
H42264Medicare UPIN