Healthcare Provider Details

I. General information

NPI: 1972504488
Provider Name (Legal Business Name): CLYDE TYRONE JACOB III M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 12/14/2023
Certification Date: 08/10/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6325 HOSPITAL PKWY
JOHNS CREEK GA
30097-5775
US

IV. Provider business mailing address

5950 CABOTAGE RD
DULUTH GA
30097-8475
US

V. Phone/Fax

Practice location:
  • Phone: 678-474-7000
  • Fax:
Mailing address:
  • Phone: 908-397-2019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01089636A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number1999591
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME162114
License Number StateFL
# 4
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberC1-0025884
License Number StateDE
# 5
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number25MA09347700
License Number StateNJ
# 6
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number81399
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: