Provider Demographics
NPI:1518526003
Name:ALEXIS D. JACOB, M.D., P.L.L.C.
Entity Type:Organization
Organization Name:ALEXIS D. JACOB, M.D., P.L.L.C.
Other - Org Name:VASCULAR ASSOCIATES OF NORTH TEXAS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXIS
Authorized Official - Middle Name:D
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-686-9406
Mailing Address - Street 1:1900 MCKINNEY AVE APT 1011
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-1718
Mailing Address - Country:US
Mailing Address - Phone:281-686-9406
Mailing Address - Fax:
Practice Address - Street 1:4001 W 15TH ST STE 335
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75093-5859
Practice Address - Country:US
Practice Address - Phone:469-562-1992
Practice Address - Fax:469-249-3510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-10
Last Update Date:2021-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular SurgeryGroup - Multi-Specialty
No207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX402462YYWMedicaid