Provider Demographics
NPI:1992723241
Name:CHEMMALAKUZHY, JACOB (MD)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:
Last Name:CHEMMALAKUZHY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JAKE
Other - Middle Name:
Other - Last Name:CHEMMALAKUZHY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6750 N MACARTHUR BLVD STE 201
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75039-2470
Mailing Address - Country:US
Mailing Address - Phone:469-963-0656
Mailing Address - Fax:
Practice Address - Street 1:6750 N MACARTHUR BLVD
Practice Address - Street 2:STE 201
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75039-2470
Practice Address - Country:US
Practice Address - Phone:972-428-3298
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002010037207R00000X, 207RC0000X, 207RI0011X
TXM3986207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX181302403Medicaid
TX181302402Medicaid
TX181302404Medicaid
H47157Medicare UPIN
TX181302402Medicaid
TXTXB113030Medicare PIN
TXP00927063Medicare PIN
TX181302403Medicaid