Provider Demographics
NPI:1376640474
Name:JACOB, POTHEN (MD)
Entity Type:Individual
Prefix:
First Name:POTHEN
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2228
Mailing Address - Street 2:4601 STATE ST SUITE #210
Mailing Address - City:E ST LOUIS
Mailing Address - State:IL
Mailing Address - Zip Code:62205-1359
Mailing Address - Country:US
Mailing Address - Phone:618-874-3700
Mailing Address - Fax:618-874-5031
Practice Address - Street 1:4601 STATE ST
Practice Address - Street 2:SUITE #210
Practice Address - City:E ST LOUIS
Practice Address - State:IL
Practice Address - Zip Code:62205-1359
Practice Address - Country:US
Practice Address - Phone:618-874-3700
Practice Address - Fax:618-874-5031
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL3648725208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
D10042Medicare UPIN