Provider Demographics
NPI:1215998737
Name:KEUM, JACOB SUNG SIK (DO)
Entity type:Individual
Prefix:DR
First Name:JACOB SUNG
Middle Name:SIK
Last Name:KEUM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:GRIDLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95948-0097
Mailing Address - Country:US
Mailing Address - Phone:530-846-9020
Mailing Address - Fax:530-846-9075
Practice Address - Street 1:1600 MORGAN ST
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-3497
Practice Address - Country:US
Practice Address - Phone:319-524-7150
Practice Address - Fax:319-524-5317
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-01
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY227598204D00000X, 207QG0300X, 208D00000X
KY03623207P00000X
CA20A13246207PE0004X
IADO-04697207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical ServicesGroup - Multi-Specialty
No204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02461874Medicaid
NYI 01454Medicare UPIN
NY5706 N 1Medicare ID - Type Unspecified
NY02461874Medicaid