MEDICARE: MR. POTHEN JACOB MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207RG0100X	Gastroenterology Physician	ME55603	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
5	100013671	OTHER		RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier Issuer
1	225659	OTHER	AMERIGROUP
2	2905049	OTHER	UNITED HEALTHCARE
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
4	08999	OTHER	BCBS FLORIDA
6	1035494	OTHER	CAREPLUS
7	206516	OTHER	AV MED
8	9630253	OTHER	GHI
9	10694801	OTHER	CITRUS HEALTHCARE
10	1200283-007	OTHER	CIGNA
11	4248344	OTHER	AETNA
12	01990	OTHER	WELLCARE

General Provider Information

NPI Number	:	1467423004
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. POTHEN JACOB MD

Provider Business Mailing Address
First Line	:	3001 EXECUTIVE DR
Second Line	:
City	:	CLEARWATER
State	:	FL
Zip	:	33762-5323
Country	:	US
Telephone Number	:	727-347-0005
Fax Number	:	727-541-6558

Provider Business Practice Location Address
First Line	:	1840 MEASE DR STE 305
Second Line	:
City	:	SAFETY HARBOR
State	:	FL
Zip	:	34695-6605
Country	:	US
Telephone Number	:	727-796-4166
Fax Number	:	727-669-5849

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/31/2006
Last Update Date	:	10/05/2020

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Directions to “ MR. POTHEN JACOB MD” Practice Location

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