Provider Demographics
NPI:1093781296
Name:JACOB, ABRAHAM (MD)
Entity Type:Individual
Prefix:MR
First Name:ABRAHAM
Middle Name:
Last Name:JACOB
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 1:300 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-7027
Mailing Address - Country:US
Mailing Address - Phone:207-795-7575
Mailing Address - Fax:207-344-0350
Practice Address - Street 1:300 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-7027
Practice Address - Country:US
Practice Address - Phone:207-795-7575
Practice Address - Fax:207-344-0350
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA200002207Q00000X
MEMD20222208M00000X, 207Q00000X
NH14874207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1053538Medicaid
LA4J487Medicare ID - Type Unspecified
LA1053538Medicaid