Provider Demographics
NPI:1972504488
Name:JACOB, CLYDE TYRONE III (MD)
Entity Type:Individual
Prefix:
First Name:CLYDE
Middle Name:TYRONE
Last Name:JACOB
Suffix:III
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 1:5950 CABOTAGE RD
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30097-8475
Mailing Address - Country:US
Mailing Address - Phone:908-397-2019
Mailing Address - Fax:
Practice Address - Street 1:6325 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-5775
Practice Address - Country:US
Practice Address - Phone:678-474-7000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2023-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01089636A207V00000X
NY1999591207V00000X
FLME162114207V00000X
DEC1-0025884207V00000X
NJ25MA09347700207V00000X
GA81399207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02219496Medicaid
NY535E91Medicare ID - Type Unspecified
NY02219496Medicaid