Provider Demographics
NPI:1992873046
Name:YANNETTA, JACOB CARMEN III (DO)
Entity type:Individual
Prefix:DR
First Name:JACOB
Middle Name:CARMEN
Last Name:YANNETTA
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2141 N FAIRFIELD RD
Mailing Address - Street 2:STE. B
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2578
Mailing Address - Country:US
Mailing Address - Phone:937-458-0025
Mailing Address - Fax:937-458-0212
Practice Address - Street 1:2141 N FAIRFIELD RD
Practice Address - Street 2:STE. B
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2578
Practice Address - Country:US
Practice Address - Phone:937-458-0025
Practice Address - Fax:937-458-0212
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH34.008653208600000X
OH340086532086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2774869Medicaid
OH2774869Medicaid