Provider Demographics
NPI:1467423004
Name:JACOB, POTHEN (MD)
Entity Type:Individual
Prefix:MR
First Name:POTHEN
Middle Name:
Last Name:JACOB
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 1:3001 EXECUTIVE DR
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33762-5323
Mailing Address - Country:US
Mailing Address - Phone:727-347-0005
Mailing Address - Fax:727-541-6558
Practice Address - Street 1:1840 MEASE DR STE 305
Practice Address - Street 2:
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695-6605
Practice Address - Country:US
Practice Address - Phone:727-796-4166
Practice Address - Fax:727-669-5849
Is Sole Proprietor?:No
Enumeration Date:2006-01-31
Last Update Date:2020-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME55603207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
225659OtherAMERIGROUP
2905049OtherUNITED HEALTHCARE
FL055528200Medicaid
08999OtherBCBS FLORIDA
100013671OtherRAILROAD MEDICARE
1035494OtherCAREPLUS
206516OtherAV MED
9630253OtherGHI
10694801OtherCITRUS HEALTHCARE
1200283-007OtherCIGNA
4248344OtherAETNA
01990OtherWELLCARE
225659OtherAMERIGROUP
FLC43849Medicare UPIN