Provider Demographics
NPI:1053330175
Name:JOSEPH, JACOB K (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:K
Last Name:JOSEPH
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:PO BOX 3528
Mailing Address - Street 2:
Mailing Address - City:FORT SMITH
Mailing Address - State:AR
Mailing Address - Zip Code:72913-3528
Mailing Address - Country:US
Mailing Address - Phone:479-274-2000
Mailing Address - Fax:479-274-2194
Practice Address - Street 1:6801 ROGERS AVE
Practice Address - Street 2:
Practice Address - City:FORT SMITH
Practice Address - State:AR
Practice Address - Zip Code:72903-4067
Practice Address - Country:US
Practice Address - Phone:479-274-3200
Practice Address - Fax:479-274-3289
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-2646207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
1053330175OtherRR MEDICARE
AR141426001Medicaid
G19106Medicare UPIN
AR141426001Medicaid