Provider Demographics
NPI:1306112644
Name:JACOB, DEXTER DOROMAL (MD)
Entity type:Individual
Prefix:
First Name:DEXTER
Middle Name:DOROMAL
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 1:207 N BROAD ST FL 3
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-1500
Mailing Address - Country:US
Mailing Address - Phone:610-279-1370
Mailing Address - Fax:610-279-1372
Practice Address - Street 1:609 W GERMANTOWN PIKE STE 120
Practice Address - Street 2:
Practice Address - City:EAST NORRITON
Practice Address - State:PA
Practice Address - Zip Code:19403-4243
Practice Address - Country:US
Practice Address - Phone:610-279-1370
Practice Address - Fax:610-279-1372
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD459805207RC0000X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1037689880003Medicaid