Healthcare Provider Details

I. General information

NPI: 1255773222
Provider Name (Legal Business Name): JACOB A PANICI D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2013
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 PARKWAY OFFICE CT STE 100
CARY NC
27518-7429
US

IV. Provider business mailing address

1514 GLENWOOD AVE GLENWOOD AVENUE FOOT AND ANKLE, PLLC
RALEIGH NC
27608-2368
US

V. Phone/Fax

Practice location:
  • Phone: 919-481-3338
  • Fax:
Mailing address:
  • Phone: 919-829-0076
  • Fax: 919-836-9094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number635
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number635
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number635
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: