Basic Information
| Provider Information | |||||||||
| NPI: | 1386969210 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WHITE | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 32 | ||||||||
| Address2: | |||||||||
| City: | NORTHBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 600650032 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2243180118 | ||||||||
| FaxNumber: | 8479194615 | ||||||||
| Practice Location | |||||||||
| Address1: | 1264 SAINT NICHOLAS AVE | ||||||||
| Address2: | |||||||||
| City: | NEW YORK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 100337263 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3475321845 | ||||||||
| FaxNumber: | 7183011099 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/04/2010 | ||||||||
| LastUpdateDate: | 11/29/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0204X | 264822 | NY | Y | Allopathic & Osteopathic Physicians | Radiology | Vascular & Interventional Radiology |
ID Information
| ID | Type | State | Issuer | Description | 04887023 | 05 | NY | MEDICAID |