=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669935128
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RADIM JACOB
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/11/2019
-----------------------------------------------------
Last Update Date | 08/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2001 KINGSLEY AVE
-----------------------------------------------------
City | ORANGE PARK
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32073-5156
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-639-2000
-----------------------------------------------------
Fax | 904-639-2015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1592 PORTER LAKES DR
-----------------------------------------------------
City | JACKSONVILLE
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32218-9047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 904-316-4972
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | ME155370
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------