Provider Demographics
NPI:1932172467
Name:DEAN, JACOB THOMAS (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:THOMAS
Last Name:DEAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 339
Mailing Address - Street 2:
Mailing Address - City:ENON
Mailing Address - State:OH
Mailing Address - Zip Code:45323-0339
Mailing Address - Country:US
Mailing Address - Phone:937-864-7363
Mailing Address - Fax:937-864-5895
Practice Address - Street 1:7790 DAYTON RD
Practice Address - Street 2:SUITE B
Practice Address - City:FAIRBORN
Practice Address - State:OH
Practice Address - Zip Code:45324-1442
Practice Address - Country:US
Practice Address - Phone:937-864-7363
Practice Address - Fax:937-864-5895
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2010-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35081458207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2357917Medicaid
OHH75010Medicare UPIN
OHDE4097305Medicare ID - Type Unspecified