Provider Demographics
NPI:1720020431
Name:OOMMEN, JACOB SAJ (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:SAJ
Last Name:OOMMEN
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 1:19204 N 93RD WAY
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-5528
Mailing Address - Country:US
Mailing Address - Phone:480-280-7007
Mailing Address - Fax:480-821-9555
Practice Address - Street 1:19204 N 93RD WAY
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-5528
Practice Address - Country:US
Practice Address - Phone:480-821-9339
Practice Address - Fax:480-821-9555
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-25365207RI0200X
MO112403207RI0200X
IL036-087704207RI0200X
AZ37316207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ240491Medicaid
AZ37316OtherLICENSE
AZZ117764Medicare PIN
AZ37316OtherLICENSE
AZ240491Medicaid