Provider Demographics
NPI:1417020744
Name:JACOB, MATTEETHRA CHANDY (MD)
Entity type:Individual
Prefix:
First Name:MATTEETHRA
Middle Name:CHANDY
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 1:8520 KNIGHT RD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77054-3808
Mailing Address - Country:US
Mailing Address - Phone:713-961-4962
Mailing Address - Fax:713-355-7991
Practice Address - Street 1:8520 KNIGHT ROAD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77054-3808
Practice Address - Country:US
Practice Address - Phone:713-790-1335
Practice Address - Fax:713-797-1858
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXF2730207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0A3253Medicare PIN