Provider Demographics
NPI:1942236278
Name:STUART JACOB DPM PA
Entity Type:Organization
Organization Name:STUART JACOB DPM PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:STUART
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:609-386-0217
Mailing Address - Street 1:319 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-1343
Mailing Address - Country:US
Mailing Address - Phone:609-386-0217
Mailing Address - Fax:609-386-2205
Practice Address - Street 1:319 W BROAD ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-1343
Practice Address - Country:US
Practice Address - Phone:609-386-0217
Practice Address - Fax:609-386-2205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMD01892213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
2093185000OtherINDEPENDENCE BLUE SHIELD
NJ5486906Medicaid
2093185000OtherAMERIHEALTH
2093185000OtherKEYSTONE HEALTH PLAN EAST
2093185000OtherINDEPENDENCE BLUE SHIELD PERSONAL CHOICE
480033923OtherPALMETTO MEDICARE
NJ7159901Medicaid
NJ6324401Medicaid
NJ7159901Medicaid
NJGR60668Medicare PIN
NJ6324401Medicaid
NJT14020Medicare UPIN
NJ5486906Medicaid