Provider Demographics
NPI:1710066881
Name:JACOB, BRUCE MICHAEL (DPM)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:MICHAEL
Last Name:JACOB
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6689 ORCHARD LAKE RD # 302
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3404
Mailing Address - Country:US
Mailing Address - Phone:248-757-0030
Mailing Address - Fax:248-757-0025
Practice Address - Street 1:6689 ORCHARD LAKE RD # 302
Practice Address - Street 2:
Practice Address - City:WEST BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48322-3404
Practice Address - Country:US
Practice Address - Phone:248-757-0030
Practice Address - Fax:248-757-0025
Is Sole Proprietor?:No
Enumeration Date:2006-11-02
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000789213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIT34570Medicare UPIN
MIOM34570Medicare ID - Type Unspecified