Provider Demographics
NPI:1427303437
Name:JACOB, DALAL FARID (MD)
Entity type:Individual
Prefix:
First Name:DALAL
Middle Name:FARID
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 CHEROKEE DR
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:AR
Mailing Address - Zip Code:72112-9998
Mailing Address - Country:US
Mailing Address - Phone:870-523-5360
Mailing Address - Fax:
Practice Address - Street 1:1224 CHEROKEE DR
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:AR
Practice Address - Zip Code:72112-9998
Practice Address - Country:US
Practice Address - Phone:870-523-5360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-16
Last Update Date:2012-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR-3150207ZP0102X, 207ZP0105X, 282NR1301X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
No207ZP0105XAllopathic & Osteopathic PhysiciansPathologyClinical Pathology/Laboratory Medicine
No282NR1301XHospitalsGeneral Acute Care HospitalRural
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARR-3150OtherARKANSAS STATE MEDICAL LICENSE