Basic Information
| Provider Information | |||||||||
| NPI: | 1689679342 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | LIONEL | ||||||||
| MiddleName: | NEWMAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1295 | ||||||||
| Address2: | |||||||||
| City: | BLUEFIELD | ||||||||
| State: | WV | ||||||||
| PostalCode: | 247011295 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3043234320 | ||||||||
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| Practice Location | |||||||||
| Address1: | 736 BATTLEFIELD BLVD N | ||||||||
| Address2: | |||||||||
| City: | CHESAPEAKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 233204941 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7573128121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2005 | ||||||||
| LastUpdateDate: | 11/21/2017 | ||||||||
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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 | 207ZP0102X | 0101051274 | VA | Y | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology |
ID Information
| ID | Type | State | Issuer | Description | 6608159 | 05 | VA | MEDICAID | 220032663 | 01 | RAILROAD MEDICARE | OTHER | 245660 | 01 | VA | ANTHEM | OTHER |