Provider Demographics
NPI:1891374302
Name:IVEY, JACOB (DPM)
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:
Last Name:IVEY
Suffix:
Gender:
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15815 SHADDOCK DR STE 130
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-5773
Mailing Address - Country:US
Mailing Address - Phone:813-400-1140
Mailing Address - Fax:813-701-9132
Practice Address - Street 1:15815 SHADDOCK DR STE 130
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-5773
Practice Address - Country:US
Practice Address - Phone:407-605-2321
Practice Address - Fax:407-671-4155
Is Sole Proprietor?:No
Enumeration Date:2021-04-03
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO4464213EP1101X, 213ES0103X, 213ES0131X, 213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Multi-Specialty
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
No213ES0131XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLYC4QHOtherBCBS FL BLUE
16150857OtherCAQH