Provider Demographics
NPI:1184730962
Name:JACOB JOSEPH M.D., P.A.
Entity type:Organization
Organization Name:JACOB JOSEPH M.D., P.A.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JACOB
Authorized Official - Middle Name:
Authorized Official - Last Name:JOSEPH
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PA
Authorized Official - Phone:941-746-1662
Mailing Address - Street 1:PO BOX 15179
Mailing Address - Street 2:
Mailing Address - City:BRADENTON
Mailing Address - State:FL
Mailing Address - Zip Code:34280-5179
Mailing Address - Country:US
Mailing Address - Phone:941-746-1662
Mailing Address - Fax:941-747-4394
Practice Address - Street 1:2820 MANATEE AVE W
Practice Address - Street 2:
Practice Address - City:BRADENTON
Practice Address - State:FL
Practice Address - Zip Code:34205-4237
Practice Address - Country:US
Practice Address - Phone:941-746-1662
Practice Address - Fax:941-747-4394
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-22
Last Update Date:2007-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME46458207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL40943OtherBLUE CROSS BLUE SHIELD
FL40943Medicare ID - Type UnspecifiedGROUP NUMBER