Provider Demographics
NPI:1477247948
Name:JACOB, BENNA THAYIL (DO)
Entity Type:Individual
Prefix:DR
First Name:BENNA
Middle Name:THAYIL
Last Name:JACOB
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:130 RADCLIFFE RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803-1218
Mailing Address - Country:US
Mailing Address - Phone:516-236-4236
Mailing Address - Fax:
Practice Address - Street 1:222 STATION PLZ N STE 509
Practice Address - Street 2:
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501-3893
Practice Address - Country:US
Practice Address - Phone:516-663-2381
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-06
Last Update Date:2023-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program