Provider Demographics
NPI:1568454163
Name:JACOBS, JOHN P (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:P
Last Name:JACOBS
Suffix:
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 1:225 E NORTH ST APT 505
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-1334
Mailing Address - Country:US
Mailing Address - Phone:317-955-9747
Mailing Address - Fax:
Practice Address - Street 1:1401 CHESTER BLVD
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-1908
Practice Address - Country:US
Practice Address - Phone:765-983-3168
Practice Address - Fax:765-983-3275
Is Sole Proprietor?:No
Enumeration Date:2005-08-19
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010458642085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000588411OtherANTHEM PIN
IN1487680518OtherGROUP NPI
IN200288740OtherGROUP MEDICAID
IN200109120Medicaid
IN100194370OtherGROUP MEDICAID
IN200109120Medicaid
F67230Medicare UPIN
IN100194370OtherGROUP MEDICAID
IN1487680518OtherGROUP NPI