Provider Demographics
NPI:1477539567
Name:JACOB, MARIAMMA (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIAMMA
Middle Name:
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 KATHARINA PL
Mailing Address - Street 2:
Mailing Address - City:TOWNSHIP OF WASHINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07676-4125
Mailing Address - Country:US
Mailing Address - Phone:201-447-6609
Mailing Address - Fax:201-447-6609
Practice Address - Street 1:451 CLARKSON AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-2057
Practice Address - Country:US
Practice Address - Phone:718-245-3638
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY191017208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics