Provider Demographics
NPI:1730323254
Name:EDWARDS, JACOB (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:EDWARDS
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 1:126 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-1980
Mailing Address - Country:US
Mailing Address - Phone:334-793-1881
Mailing Address - Fax:334-340-5918
Practice Address - Street 1:5565 MONTGOMERY HWY
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1552
Practice Address - Country:US
Practice Address - Phone:334-699-3733
Practice Address - Fax:334-500-3007
Is Sole Proprietor?:No
Enumeration Date:2009-04-28
Last Update Date:2020-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD.31940208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003190111DMedicaid
FL021006600Medicaid
AL141478Medicaid
AL229200Medicaid
AL51222367OtherBCBS