Provider Demographics
NPI:1487655411
Name:TAL, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:TAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JACOB
Other - Middle Name:
Other - Last Name:TAL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:23960 KATY FWY
Mailing Address - Street 2:SUITE 350
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-1339
Mailing Address - Country:US
Mailing Address - Phone:713-464-1845
Mailing Address - Fax:281-392-5081
Practice Address - Street 1:23960 KATY FWY
Practice Address - Street 2:SUITE 350
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-1339
Practice Address - Country:US
Practice Address - Phone:713-464-1845
Practice Address - Fax:281-392-5081
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-01
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF7630174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0025NGOtherBCBS
TX179782101Medicaid
TX0025NGOtherBCBS
C22448Medicare UPIN