Healthcare Provider Details

I. General information

NPI: 1760045322
Provider Name (Legal Business Name): JACOB YOUNGTAIK MOK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 09/09/2025
Certification Date: 09/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3970 DEP BILL CANTRELL MEMORIAL RD
CUMMING GA
30040-3011
US

IV. Provider business mailing address

3970 DEP BILL CANTRELL MEMORIAL RD
CUMMING GA
30040-3011
US

V. Phone/Fax

Practice location:
  • Phone: 678-513-2273
  • Fax: 678-513-8869
Mailing address:
  • Phone: 678-513-2273
  • Fax: 678-513-8869

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number92063
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: