Provider Demographics
NPI:1912090689
Name:JACOB, EMMANUEL EGIPTO (MD)
Entity Type:Individual
Prefix:DR
First Name:EMMANUEL
Middle Name:EGIPTO
Last Name:JACOB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39 SOUTH RIVER STREET
Mailing Address - Street 2:
Mailing Address - City:PLAINS
Mailing Address - State:PA
Mailing Address - Zip Code:18705
Mailing Address - Country:US
Mailing Address - Phone:570-822-9514
Mailing Address - Fax:570-823-8039
Practice Address - Street 1:39 SOUTH RIVER STREET
Practice Address - Street 2:
Practice Address - City:PLAINS
Practice Address - State:PA
Practice Address - Zip Code:18705
Practice Address - Country:US
Practice Address - Phone:570-822-9514
Practice Address - Fax:570-823-8039
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2010-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAAK000322L171100000X
PAMD026644E174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No171100000XOther Service ProvidersAcupuncturist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC34373Medicare UPIN
PA459803Medicare ID - Type Unspecified