Provider Demographics
NPI:1477043248
Name:JACOB, JOBY CHACKO (MD)
Entity Type:Individual
Prefix:DR
First Name:JOBY
Middle Name:CHACKO
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:PO BOX 7410725
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60674-0725
Mailing Address - Country:US
Mailing Address - Phone:215-943-2000
Mailing Address - Fax:
Practice Address - Street 1:1411 WOODBOURNE RD
Practice Address - Street 2:
Practice Address - City:LEVITTOWN
Practice Address - State:PA
Practice Address - Zip Code:19057-1540
Practice Address - Country:US
Practice Address - Phone:215-943-2000
Practice Address - Fax:215-943-4439
Is Sole Proprietor?:No
Enumeration Date:2018-05-16
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD474033207R00000X
PAMT216142390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program