Provider Demographics
NPI:1770772246
Name:MOHAN JACOB,M.D.,P.A.
Entity type:Organization
Organization Name:MOHAN JACOB,M.D.,P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JACOB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:281-446-5555
Mailing Address - Street 1:18955 N MEMORIAL DR
Mailing Address - Street 2:SUITE 440
Mailing Address - City:HUMBLE
Mailing Address - State:TX
Mailing Address - Zip Code:77338-4271
Mailing Address - Country:US
Mailing Address - Phone:281-446-5555
Mailing Address - Fax:
Practice Address - Street 1:18955 MEMORIAL NORTH
Practice Address - Street 2:SUITE 440
Practice Address - City:HUMBLE
Practice Address - State:TX
Practice Address - Zip Code:77338-4271
Practice Address - Country:US
Practice Address - Phone:281-446-5555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2009-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG5935207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX082533301Medicaid
TXDN1411Medicare PIN
TX00F90EMedicare PIN
TX082533301Medicaid
TX010017401Medicare PIN