Provider Demographics
NPI:1669935128
Name:JACOB, RADIM
Entity type:Individual
Prefix:
First Name:RADIM
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1592 PORTER LAKES DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32218-9047
Mailing Address - Country:US
Mailing Address - Phone:904-316-4972
Mailing Address - Fax:
Practice Address - Street 1:2001 KINGSLEY AVE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-5156
Practice Address - Country:US
Practice Address - Phone:904-639-2000
Practice Address - Fax:904-639-2015
Is Sole Proprietor?:No
Enumeration Date:2019-04-11
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME155370207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine