Provider Demographics
NPI:1972597193
Name:JACOB, VIOLA MAF (MD)
Entity type:Individual
Prefix:
First Name:VIOLA
Middle Name:MAF
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:PO BOX 121176
Mailing Address - Street 2:
Mailing Address - City:CLERMONT
Mailing Address - State:FL
Mailing Address - Zip Code:34712-1176
Mailing Address - Country:US
Mailing Address - Phone:407-215-4999
Mailing Address - Fax:888-762-3102
Practice Address - Street 1:1451 HAVEN DR
Practice Address - Street 2:
Practice Address - City:OVIEDO
Practice Address - State:FL
Practice Address - Zip Code:32765-5286
Practice Address - Country:US
Practice Address - Phone:407-215-4999
Practice Address - Fax:352-394-5992
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-02
Last Update Date:2021-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME90116207R00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279329600Medicaid
FL279329600Medicaid
43943Medicare ID - Type Unspecified