Provider Demographics
NPI:1356409866
Name:JACOBS, ELLIOT WILLIAM (MD)
Entity type:Individual
Prefix:
First Name:ELLIOT
Middle Name:WILLIAM
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 1:815 PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10021
Mailing Address - Country:US
Mailing Address - Phone:212-570-6080
Mailing Address - Fax:212-879-7002
Practice Address - Street 1:815 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:212-570-6080
Practice Address - Fax:212-879-7002
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYMD112279208200000X
FLME98407208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00348554Medicaid
NYAJ5184065OtherDEA
C08260Medicare UPIN
NYAJ5184065OtherDEA