Basic Information
| Provider Information | |||||||||
| NPI: | 1548433345 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | BRIAN | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9800 BROADWAY EXTENSION | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054245426 | ||||||||
| FaxNumber: | 4054245431 | ||||||||
| Practice Location | |||||||||
| Address1: | 9800 BROADWAY EXTENSION | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | OKLAHOMA CITY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4054245426 | ||||||||
| FaxNumber: | 4054245431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/12/2008 | ||||||||
| LastUpdateDate: | 02/03/2016 | ||||||||
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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 | 207X00000X | 390200000X | OH | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | 207XS0114X | 5494 | OK | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Adult Reconstructive Orthopaedic Surgery | 2251X0800X | OH-9638 | OH | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.