Provider Demographics
NPI:1457472391
Name:JACOB T JOSEPH MD PC
Entity Type:Organization
Organization Name:JACOB T JOSEPH MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:703-273-4762
Mailing Address - Street 1:10721 MAIN ST
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22030-6914
Mailing Address - Country:US
Mailing Address - Phone:703-273-4762
Mailing Address - Fax:703-591-7719
Practice Address - Street 1:10721 MAIN ST
Practice Address - Street 2:SUITE 1100
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22030-6914
Practice Address - Country:US
Practice Address - Phone:703-273-4762
Practice Address - Fax:703-591-7719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-02
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101034461207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
632706Medicare ID - Type UnspecifiedMEDICARE