Provider Demographics
NPI:1942267448
Name:JACOB, MOHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAN
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 1:18955 MEMORIAL NORTH
Mailing Address - Street 2:SUITE 440
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338
Mailing Address - Country:US
Mailing Address - Phone:281-446-5555
Mailing Address - Fax:281-548-1002
Practice Address - Street 1:18955 MEMORIAL NORTH
Practice Address - Street 2:SUITE 440
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338
Practice Address - Country:US
Practice Address - Phone:281-446-5555
Practice Address - Fax:281-548-1002
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2007-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5935207RC0000X
GA020876207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX133869101Medicaid
TXC17363Medicare UPIN
TX84J476Medicare PIN