Provider Demographics
NPI:1194303594
Name:JOHN, LIJI JACOB (MD)
Entity type:Individual
Prefix:DR
First Name:LIJI
Middle Name:JACOB
Last Name:JOHN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LIJI
Other - Middle Name:
Other - Last Name:JACOB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2704 N GALLOWAY AVE STE 103
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-6379
Mailing Address - Country:US
Mailing Address - Phone:214-660-2500
Mailing Address - Fax:833-535-1076
Practice Address - Street 1:2704 N GALLOWAY AVE STE 103
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-6379
Practice Address - Country:US
Practice Address - Phone:214-660-2500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-29
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV3025207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty