Provider Demographics
NPI:1679500813
Name:JACOB, TIMOTHY DOUGLAS (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DOUGLAS
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 1:8199 MCKNIGHT RD STE 102
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15237-5749
Mailing Address - Country:US
Mailing Address - Phone:412-364-5490
Mailing Address - Fax:412-364-5493
Practice Address - Street 1:8199 MCKNIGHT RD STE 102
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15237-5749
Practice Address - Country:US
Practice Address - Phone:412-364-5490
Practice Address - Fax:412-364-5493
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2022-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042446L208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0014797690006Medicaid
F80821OtherHEALTH AMERICA
PA770837OtherBLUE CROSS
102805OtherUPMC
F80821Medicare UPIN
F80821OtherHEALTH AMERICA