Provider Demographics
NPI:1558340869
Name:NEATHAWK, JACOB JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:NEATHAWK
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1802 BRAEBURN DR
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:VA
Mailing Address - Zip Code:24153-7357
Mailing Address - Country:US
Mailing Address - Phone:540-772-3430
Mailing Address - Fax:540-776-2051
Practice Address - Street 1:1802 BRAEBURN DR
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:VA
Practice Address - Zip Code:24153-7357
Practice Address - Country:US
Practice Address - Phone:540-772-3430
Practice Address - Fax:540-776-2051
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101028129207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAP00277033OtherMEDICARE RAILROAD
B09047Medicare UPIN
009214L84Medicare PIN