Provider Demographics
NPI:1043574478
Name:MOE, JACOB LAYNE (DO)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:LAYNE
Last Name:MOE
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:29992 NORTHWESTERN HWY STE C
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-3292
Mailing Address - Country:US
Mailing Address - Phone:248-851-1430
Mailing Address - Fax:248-851-5319
Practice Address - Street 1:32255 NORTHWESTERN HWY STE 214
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334
Practice Address - Country:US
Practice Address - Phone:248-855-5620
Practice Address - Fax:248-855-5628
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2019-12-06
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Provider Licenses
StateLicense IDTaxonomies
MI5101019711207R00000X, 207RE0101X
MI5315054293207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1043574478Medicaid
MIMI4989641OtherMEDICARE PTAN