Provider Demographics
NPI:1851336028
Name:JACOB, MARTY (MD)
Entity Type:Individual
Prefix:
First Name:MARTY
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5700 LAKE WORTH RD
Mailing Address - Street 2:#204
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33463-4727
Mailing Address - Country:US
Mailing Address - Phone:561-968-7968
Mailing Address - Fax:561-964-4603
Practice Address - Street 1:2015 OCEAN DR
Practice Address - Street 2:#8
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-5131
Practice Address - Country:US
Practice Address - Phone:561-737-4777
Practice Address - Fax:561-737-0996
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2011-02-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME81999207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H52504Medicare UPIN
FL58767Medicare PIN