Provider Demographics
NPI:1831196831
Name:HANLON, JACOB EDWARD (DPM)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:EDWARD
Last Name:HANLON
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 1:22 OLD RUDNICK LN
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:DE
Mailing Address - Zip Code:19901-4912
Mailing Address - Country:US
Mailing Address - Phone:302-674-9255
Mailing Address - Fax:302-674-9096
Practice Address - Street 1:22 OLD RUDNICK LN
Practice Address - Street 2:
Practice Address - City:DOVER
Practice Address - State:DE
Practice Address - Zip Code:19901-4912
Practice Address - Country:US
Practice Address - Phone:302-674-9255
Practice Address - Fax:302-674-9255
Is Sole Proprietor?:No
Enumeration Date:2005-07-05
Last Update Date:2014-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEE10000168213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE98423Medicare UPIN
DE491668Medicare ID - Type Unspecified
DE3976320001Medicare NSC