Provider Demographics
NPI:1205152295
Name:DIMA, JACOB JUSTIN (DO)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:JUSTIN
Last Name:DIMA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2660 W COVELL BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5645
Mailing Address - Country:US
Mailing Address - Phone:530-747-3000
Mailing Address - Fax:
Practice Address - Street 1:2660 W COVELL BLVD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5645
Practice Address - Country:US
Practice Address - Phone:530-747-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-15
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125-058844207Q00000X
CAA12687207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine