Basic Information
| Provider Information | |||||||||
| NPI: | 1588842314 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONKLIN | ||||||||
| FirstName: | JACOB | ||||||||
| MiddleName: | EZRA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 885 N SANDUSKY AVE | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433511098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4192944991 | ||||||||
| FaxNumber: | 4192090278 | ||||||||
| Practice Location | |||||||||
| Address1: | 885 N SANDUSKY AVE | ||||||||
| Address2: | |||||||||
| City: | UPPER SANDUSKY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 433511098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4197314282 | ||||||||
| FaxNumber: | 4197314163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 12/11/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35091628 | OH | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2916778 | 05 | OH | MEDICAID |