Provider Demographics
NPI:1255773222
Name:PANICI, JACOB A (DPM)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:A
Last Name:PANICI
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 GLENWOOD AVE
Mailing Address - Street 2:GLENWOOD AVENUE FOOT AND ANKLE, PLLC
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27608-2368
Mailing Address - Country:US
Mailing Address - Phone:919-829-0076
Mailing Address - Fax:919-836-9094
Practice Address - Street 1:103 PARKWAY OFFICE CT STE 100
Practice Address - Street 2:
Practice Address - City:CARY
Practice Address - State:NC
Practice Address - Zip Code:27518-7429
Practice Address - Country:US
Practice Address - Phone:919-481-3338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-19
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC635213ES0103X, 213ES0131X, 213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4861725OtherAETNA
NCNCO458F491Medicare PIN