Provider Demographics
NPI:1134569395
Name:KALLIATH, JACOB (DO)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:KALLIATH
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10624 S. EASTERN AVE #263A
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89052
Mailing Address - Country:US
Mailing Address - Phone:760-684-0407
Mailing Address - Fax:800-604-6214
Practice Address - Street 1:20201 CRAWFORD AVE
Practice Address - Street 2:
Practice Address - City:OLYMPIA FIELDS
Practice Address - State:IL
Practice Address - Zip Code:60461
Practice Address - Country:US
Practice Address - Phone:708-679-2160
Practice Address - Fax:708-679-2161
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-02
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CODR0057617207R00000X
IN02005206A207R00000X
IL036138730208M00000X
IL12506386207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist