Basic Information
| Provider Information | |||||||||
| NPI: | 1265462873 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | RADU | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8130 ROYAL PALM BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330655703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543454333 | ||||||||
| FaxNumber: | 9543454334 | ||||||||
| Practice Location | |||||||||
| Address1: | 8130 ROYAL PALM BLVD | ||||||||
| Address2: | SUITE 102 | ||||||||
| City: | CORAL SPRINGS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330655703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543454333 | ||||||||
| FaxNumber: | 9543454334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/03/2006 | ||||||||
| LastUpdateDate: | 11/20/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RN0300X | ME89216 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Nephrology |
ID Information
| ID | Type | State | Issuer | Description | 276603500 | 05 | FL | MEDICAID |