Provider Demographics
NPI:1306968318
Name:JACOB, PIUS (MD)
Entity type:Individual
Prefix:
First Name:PIUS
Middle Name:
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 1:38188 MEDICAL CENTER AVE
Mailing Address - Street 2:
Mailing Address - City:ZEPHYRHILLS
Mailing Address - State:FL
Mailing Address - Zip Code:33540-1380
Mailing Address - Country:US
Mailing Address - Phone:813-788-1266
Mailing Address - Fax:813-788-6907
Practice Address - Street 1:38188 MEDICAL CENTER AVE
Practice Address - Street 2:
Practice Address - City:ZEPHYRHILLS
Practice Address - State:FL
Practice Address - Zip Code:33540-1380
Practice Address - Country:US
Practice Address - Phone:813-788-1266
Practice Address - Fax:813-788-6907
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2015-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME00515532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE94177Medicare UPIN
FL12984Medicare ID - Type Unspecified
FLE94177Medicare UPIN