Provider Demographics
NPI:1841435054
Name:CALVERT, JACOB RANDALL (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:RANDALL
Last Name:CALVERT
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:700 NE 87TH AVE
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98664-1913
Mailing Address - Country:US
Mailing Address - Phone:360-882-2778
Mailing Address - Fax:
Practice Address - Street 1:2525 NE 139TH ST
Practice Address - Street 2:SUITE 270
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98686-2719
Practice Address - Country:US
Practice Address - Phone:360-882-2778
Practice Address - Fax:360-604-1653
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD60280471207V00000X, 207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8912276Medicare PIN