Provider Demographics
NPI:1467719849
Name:MINA JACOB, MD, PC
Entity Type:Organization
Organization Name:MINA JACOB, MD, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MINA
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-273-6438
Mailing Address - Street 1:1300 PEACHTREE BATTLE AVE NW
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30327-1424
Mailing Address - Country:US
Mailing Address - Phone:404-273-6438
Mailing Address - Fax:
Practice Address - Street 1:1300 PEACHTREE BATTLE AVE NW
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30327-1424
Practice Address - Country:US
Practice Address - Phone:404-273-6438
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-23
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA51477261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty