Provider Demographics
NPI:1760045322
Name:MOK, JACOB YOUNGTAIK (MD)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:YOUNGTAIK
Last Name:MOK
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 1:200 S ENOTA DR NE STE 100
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-3466
Mailing Address - Country:US
Mailing Address - Phone:770-691-6385
Mailing Address - Fax:
Practice Address - Street 1:200 S ENOTA DR NE STE 100
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3466
Practice Address - Country:US
Practice Address - Phone:770-534-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-19
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA92063207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program