Provider Demographics
NPI:1316061179
Name:JACOB, RICHARD KEITH JR (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:KEITH
Last Name:JACOB
Suffix:JR
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 1:2151 W SPRING ST STE B210
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-3214
Mailing Address - Country:US
Mailing Address - Phone:770-207-5738
Mailing Address - Fax:770-266-7346
Practice Address - Street 1:2151 W SPRING ST STE B210
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:GA
Practice Address - Zip Code:30655
Practice Address - Country:US
Practice Address - Phone:770-207-5738
Practice Address - Fax:770-266-7346
Is Sole Proprietor?:No
Enumeration Date:2007-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA58881208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAVAD 000Medicare UPIN