Provider Demographics
NPI:1194771832
Name:JACOB, JOSE (MD)
Entity type:Individual
Prefix:MR
First Name:JOSE
Middle Name:
Last Name:JACOB
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34748-6845
Mailing Address - Country:US
Mailing Address - Phone:352-512-9104
Mailing Address - Fax:
Practice Address - Street 1:1215 S 9TH ST
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-6845
Practice Address - Country:US
Practice Address - Phone:352-512-9104
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2025-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200200553207RC0000X
FLME146896207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89131E0Medicaid
FL109046000Medicaid