Provider Demographics
NPI:1578631511
Name:JACOB, NIRMALA ROSE (MD)
Entity Type:Individual
Prefix:DR
First Name:NIRMALA
Middle Name:ROSE
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N ORANGE AVE APT 310
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32801-2079
Mailing Address - Country:US
Mailing Address - Phone:813-787-6475
Mailing Address - Fax:
Practice Address - Street 1:5190 S JOHN YOUNG PKWY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32839-5022
Practice Address - Country:US
Practice Address - Phone:844-665-4827
Practice Address - Fax:888-258-2307
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2023-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75726207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277885800Medicaid
FLP01139623OtherRR MCR
FLH04165Medicare UPIN
FL43654UMedicare PIN
FLP01139623OtherRR MCR