Provider Demographics
NPI:1699961490
Name:JACOB, SUNITHA BINU (MD)
Entity type:Individual
Prefix:DR
First Name:SUNITHA
Middle Name:BINU
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6200 BEACH CHANNEL DR
Mailing Address - Street 2:
Mailing Address - City:ARVERNE
Mailing Address - State:NY
Mailing Address - Zip Code:11692-1409
Mailing Address - Country:US
Mailing Address - Phone:718-945-7150
Mailing Address - Fax:718-945-2596
Practice Address - Street 1:1288 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:FAR ROCKAWAY
Practice Address - State:NY
Practice Address - Zip Code:11691-3909
Practice Address - Country:US
Practice Address - Phone:718-945-7150
Practice Address - Fax:718-868-0617
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-14
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246009207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY031988929Medicaid