Provider Demographics
NPI:1255504973
Name:HARRIS, JACOB J (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:J
Last Name:HARRIS
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 1:4620 W COMMERCIAL BLVD
Mailing Address - Street 2:SUITE 5
Mailing Address - City:TAMARAC
Mailing Address - State:FL
Mailing Address - Zip Code:33319-3320
Mailing Address - Country:US
Mailing Address - Phone:954-486-4647
Mailing Address - Fax:954-486-4649
Practice Address - Street 1:4620 W COMMERCIAL BLVD
Practice Address - Street 2:SUITE 5
Practice Address - City:TAMARAC
Practice Address - State:FL
Practice Address - Zip Code:33319-3320
Practice Address - Country:US
Practice Address - Phone:954-486-4647
Practice Address - Fax:954-486-4649
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-03
Last Update Date:2008-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 33828174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD62982Medicare UPIN