Provider Demographics
NPI:1992786313
Name:JACOBS, MICHAEL IRA (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:IRA
Last Name:JACOBS
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 1:407 E 70TH ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021-5302
Mailing Address - Country:US
Mailing Address - Phone:212-772-7190
Mailing Address - Fax:212-396-1698
Practice Address - Street 1:407 E 70TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021-5302
Practice Address - Country:US
Practice Address - Phone:212-772-7190
Practice Address - Fax:212-396-1698
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134716207N00000X, 207NS0135X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207N00000XAllopathic & Osteopathic PhysiciansDermatology
Not Answered207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
A62804Medicare UPIN
45A421Medicare ID - Type Unspecified