Provider Demographics
NPI:1821047176
Name:JACOB, SHERAJ (MD)
Entity Type:Individual
Prefix:
First Name:SHERAJ
Middle Name:
Last Name:JACOB
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:PO BOX 907790
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-0912
Mailing Address - Country:US
Mailing Address - Phone:678-997-2140
Mailing Address - Fax:
Practice Address - Street 1:2324 LIMESTONE OVERLOOK
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-7443
Practice Address - Country:US
Practice Address - Phone:770-536-8109
Practice Address - Fax:770-536-3203
Is Sole Proprietor?:No
Enumeration Date:2006-05-06
Last Update Date:2020-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057380207ZP0102X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA828689435AMedicaid
G86164Medicare UPIN
GA10BDHKLMedicare PIN
LA1496863Medicaid
GA828689435AMedicaid