Healthcare Provider Details

I. General information

NPI: 1992873046
Provider Name (Legal Business Name): JACOB CARMEN YANNETTA III D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 02/02/2026
Certification Date: 02/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 W MCCREIGHT AVE STE 106
SPRINGFIELD OH
45504-1853
US

IV. Provider business mailing address

30 W MCCREIGHT AVE STE 106
SPRINGFIELD OH
45504-1853
US

V. Phone/Fax

Practice location:
  • Phone: 937-523-9885
  • Fax: 937-523-9886
Mailing address:
  • Phone: 937-523-9885
  • Fax: 937-523-9886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number34.008653
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34.008653
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: