Provider Demographics
NPI:1679647697
Name:JACOB, LESLIE (MD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
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 1:3610 YACHT CLUB DR APT 1202
Mailing Address - Street 2:SUITE # 205
Mailing Address - City:AVENTURA
Mailing Address - State:FL
Mailing Address - Zip Code:33180-3546
Mailing Address - Country:US
Mailing Address - Phone:561-756-5606
Mailing Address - Fax:
Practice Address - Street 1:4200 SUN N LAKE BLVD
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33872-1986
Practice Address - Country:US
Practice Address - Phone:863-402-3103
Practice Address - Fax:863-402-5339
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101280924207RG0100X
FLME66002207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL119868200Medicaid
FLRM822OtherHFMG MA
FL100011557OtherRAILROAD MEDICARE
FL28906OtherBLUE CROSS BLUE SHIELD OF FLA
FL28906OtherBLUE CROSS BLUE SHIELD OF FLA