Basic Information
| Provider Information | |||||||||
| NPI: | 1467423004 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | POTHEN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 EXECUTIVE DR | ||||||||
| Address2: | |||||||||
| City: | CLEARWATER | ||||||||
| State: | FL | ||||||||
| PostalCode: | 337625323 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7273470005 | ||||||||
| FaxNumber: | 7275416558 | ||||||||
| Practice Location | |||||||||
| Address1: | 1840 MEASE DR STE 305 | ||||||||
| Address2: | |||||||||
| City: | SAFETY HARBOR | ||||||||
| State: | FL | ||||||||
| PostalCode: | 346956605 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277964166 | ||||||||
| FaxNumber: | 7276695849 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/31/2006 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RG0100X | ME55603 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
ID Information
| ID | Type | State | Issuer | Description | 225659 | 01 | AMERIGROUP | OTHER | 2905049 | 01 | UNITED HEALTHCARE | OTHER | 055528200 | 05 | FL | MEDICAID | 08999 | 01 | BCBS FLORIDA | OTHER | 100013671 | 01 | RAILROAD MEDICARE | OTHER | 1035494 | 01 | CAREPLUS | OTHER | 206516 | 01 | AV MED | OTHER | 9630253 | 01 | GHI | OTHER | 10694801 | 01 | CITRUS HEALTHCARE | OTHER | 1200283-007 | 01 | CIGNA | OTHER | 4248344 | 01 | AETNA | OTHER | 01990 | 01 | WELLCARE | OTHER |