Provider Demographics
NPI:1609871417
Name:JACOB, ANTONY THEKKUMPURAM (MD)
Entity Type:Individual
Prefix:
First Name:ANTONY
Middle Name:THEKKUMPURAM
Last Name:JACOB
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 1:30 E APPLE ST
Mailing Address - Street 2:STE L200
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45409-2932
Mailing Address - Country:US
Mailing Address - Phone:937-208-2020
Mailing Address - Fax:937-208-2109
Practice Address - Street 1:30 E APPLE ST
Practice Address - Street 2:STE L200
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2932
Practice Address - Country:US
Practice Address - Phone:937-208-2020
Practice Address - Fax:937-208-2109
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.058320208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0739366Medicaid
OH010056939Medicare PIN
OH0739366Medicaid
OHH125380Medicare PIN
D13489Medicare UPIN