Provider Demographics
NPI:1508938580
Name:CARAOTTA, JACOB G (DC,DABCO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:G
Last Name:CARAOTTA
Suffix:
Gender:M
Credentials:DC,DABCO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 E STATE ST
Mailing Address - Street 2:
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61108-2275
Mailing Address - Country:US
Mailing Address - Phone:815-398-4004
Mailing Address - Fax:815-398-4005
Practice Address - Street 1:4921 E STATE ST
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61108-2275
Practice Address - Country:US
Practice Address - Phone:815-398-4004
Practice Address - Fax:815-398-4005
Is Sole Proprietor?:No
Enumeration Date:2006-11-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005798111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
U30871Medicare UPIN
761520Medicare ID - Type Unspecified