Healthcare Provider Details

I. General information

NPI: 1720020431
Provider Name (Legal Business Name): JACOB SAJ OOMMEN M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 05/20/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19204 N 93RD WAY
SCOTTSDALE AZ
85255-5528
US

IV. Provider business mailing address

19204 N 93RD WAY
SCOTTSDALE AZ
85255-5528
US

V. Phone/Fax

Practice location:
  • Phone: 480-821-9339
  • Fax: 480-821-9555
Mailing address:
  • Phone: 480-280-7007
  • Fax: 480-821-9555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number04-25365
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number112403
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number036-087704
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number37316
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: