Provider Demographics
NPI:1720317746
Name:CROSS, JACOB THOMAS JR (MD)
Entity Type:Individual
Prefix:DR
First Name:JACOB
Middle Name:THOMAS
Last Name:CROSS
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:PO BOX 38744
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80937-8744
Mailing Address - Country:US
Mailing Address - Phone:719-538-0006
Mailing Address - Fax:855-722-7677
Practice Address - Street 1:4320 GRANTHAM CT
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-4365
Practice Address - Country:US
Practice Address - Phone:719-538-0006
Practice Address - Fax:855-722-7677
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-22
Last Update Date:2020-04-03
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
LA020008207RI0200X
CO42024207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAF76488Medicare UPIN