Healthcare Provider Details

I. General information

NPI: 1649220435
Provider Name (Legal Business Name): JACOB GEORGE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 10/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2421 W. 21ST STREET
CLOVIS NM
88101
US

IV. Provider business mailing address

2421 W. 21ST STREET
CLOVIS NM
88101
US

V. Phone/Fax

Practice location:
  • Phone: 505-763-9800
  • Fax: 505-769-1998
Mailing address:
  • Phone: 505-763-9800
  • Fax: 505-769-1998

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number92-226
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: