Provider Demographics
NPI:1245262054
Name:JACOB, DENNIS M (MD)
Entity type:Individual
Prefix:DR
First Name:DENNIS
Middle Name:M
Last Name:JACOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1400 N RITTER AVE
Practice Address - Street 2:SUITE 520
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46219-3052
Practice Address - Country:US
Practice Address - Phone:317-355-7220
Practice Address - Fax:317-355-9672
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN010339792086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
INP01198024OtherRR MEDICARE PTAN
IN100366930AMedicaid
IN266180121Medicare PIN
IN100366930AMedicaid
INP00719545Medicare PIN
IN251320OMedicare PIN
INP01198024OtherRR MEDICARE PTAN