Provider Demographics
NPI:1588842314
Name:CONKLIN, JACOB EZRA (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:EZRA
Last Name:CONKLIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:885 N SANDUSKY AVE
Mailing Address - Street 2:
Mailing Address - City:UPPER SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:43351-1098
Mailing Address - Country:US
Mailing Address - Phone:419-294-4991
Mailing Address - Fax:419-209-0278
Practice Address - Street 1:885 N SANDUSKY AVE
Practice Address - Street 2:
Practice Address - City:UPPER SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:43351-1098
Practice Address - Country:US
Practice Address - Phone:419-731-4282
Practice Address - Fax:419-731-4163
Is Sole Proprietor?:No
Enumeration Date:2008-02-04
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35091628207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2916778Medicaid
OH2916778Medicaid