Provider Demographics
NPI:1275793564
Name:JACOB & JACOB MD PA
Entity Type:Organization
Organization Name:JACOB & JACOB MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:MIREILLE
Authorized Official - Middle Name:
Authorized Official - Last Name:COLES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:954-564-8542
Mailing Address - Street 1:2101 NE 26TH ST
Mailing Address - Street 2:
Mailing Address - City:WILTON MANORS
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1535
Mailing Address - Country:US
Mailing Address - Phone:954-564-8542
Mailing Address - Fax:954-564-3364
Practice Address - Street 1:2101 NE 26TH STREET
Practice Address - Street 2:
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33305
Practice Address - Country:US
Practice Address - Phone:954-564-8542
Practice Address - Fax:954-564-3364
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-11
Last Update Date:2008-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME34383174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL93830Medicare PIN
FL93750Medicare PIN