Healthcare Provider Details

I. General information

NPI: 1720668064
Provider Name (Legal Business Name): ISA MULINGBAYAN JACOBA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2021
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY ST
PROVIDENCE RI
02903-4923
US

IV. Provider business mailing address

15 LA SALLE SQ
PROVIDENCE RI
02903-1814
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-5057
  • Fax: 401-444-8514
Mailing address:
  • Phone: 401-444-6779
  • Fax: 401-444-6912

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number1021467
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberMD20614
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: