Provider Demographics
NPI:1295178580
Name:LASSITER, JACOB RANDALL (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:RANDALL
Last Name:LASSITER
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 1:550 REDSTONE AVE W STE 470
Mailing Address - Street 2:
Mailing Address - City:CRESTVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:32536-6457
Mailing Address - Country:US
Mailing Address - Phone:850-689-2229
Mailing Address - Fax:
Practice Address - Street 1:550 REDSTONE AVE W STE 470
Practice Address - Street 2:
Practice Address - City:CRESTVIEW
Practice Address - State:FL
Practice Address - Zip Code:32536-6457
Practice Address - Country:US
Practice Address - Phone:850-689-2229
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-17
Last Update Date:2021-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS24652207V00000X
ALMD.34009390200000X
FLME140756207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS05923357Medicaid