Provider Demographics
NPI:1255302428
Name:HYPPOLITE, JACOB (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:HYPPOLITE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 SNAPDRAGON LOOP
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34212-3901
Mailing Address - Country:US
Mailing Address - Phone:941-538-0991
Mailing Address - Fax:
Practice Address - Street 1:10000 BAY PINES BLVD
Practice Address - Street 2:
Practice Address - City:BAY PINES
Practice Address - State:FL
Practice Address - Zip Code:33744
Practice Address - Country:US
Practice Address - Phone:727-398-6661
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA055526207R00000X
FLOS 9078207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA89921409859OtherBCBS
GAP00262575OtherRAILROAD MEDICARE
GA668053191AMedicaid
GAP00262575OtherRAILROAD MEDICARE
GAI17919Medicare UPIN