Provider Demographics
NPI:1760985501
Name:FISCHER, JACOB ANTHONY (DO)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:ANTHONY
Last Name:FISCHER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 54TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33703-2642
Mailing Address - Country:US
Mailing Address - Phone:213-200-4597
Mailing Address - Fax:
Practice Address - Street 1:6500 38TH AVE N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-1629
Practice Address - Country:US
Practice Address - Phone:727-384-7727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-16
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS-2219208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice