Healthcare Provider Details

I. General information

NPI: 1942675764
Provider Name (Legal Business Name): JACOB CHOI D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2015
Last Update Date: 03/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 SHORT AVE
ODESSA FL
33556-3445
US

IV. Provider business mailing address

7005 NIGHTWALKER RD
WEEKI WACHEE FL
34613-6349
US

V. Phone/Fax

Practice location:
  • Phone: 727-372-9922
  • Fax:
Mailing address:
  • Phone: 352-556-2524
  • Fax: 352-556-5465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS14195
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License NumberOS14195
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: