Provider Demographics
NPI:1386668903
Name:JACOB, ANNAMMA J (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNAMMA
Middle Name:J
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:1635 N GEORGE MASON DR
Mailing Address - Street 2:STE 240
Mailing Address - City:ARLINGTON
Mailing Address - State:VA
Mailing Address - Zip Code:22205-3681
Mailing Address - Country:US
Mailing Address - Phone:703-528-1329
Mailing Address - Fax:703-522-4915
Practice Address - Street 1:1635 N GEORGE MASON DR
Practice Address - Street 2:STE 240
Practice Address - City:ARLINGTON
Practice Address - State:VA
Practice Address - Zip Code:22205-3681
Practice Address - Country:US
Practice Address - Phone:703-528-1329
Practice Address - Fax:703-522-4915
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101034078207KA0200X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
No207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
081723OtherANTHEM
VA60-4923-1Medicaid
54-1272326OtherUNITED HEALTHCARE
29164OtherM.D.I.P.A
8803OtherCAREFIRST BLUE CROSS BLUE
8803OtherCAREFIRST BLUE CROSS BLUE
081723OtherANTHEM