Provider Demographics
NPI:1134654924
Name:MARKS, JACOB MICHAEL (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:MICHAEL
Last Name:MARKS
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 1:4111 S SILVERADO ST UNIT 188
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-0119
Mailing Address - Country:US
Mailing Address - Phone:724-713-7471
Mailing Address - Fax:
Practice Address - Street 1:1981 E BONANZA CT STE 102
Practice Address - Street 2:
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-8014
Practice Address - Country:US
Practice Address - Phone:480-466-7355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-28
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ72603208200000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program