Basic Information
| Provider Information | |||||||||
| NPI: | 1851336028 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | MARTY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5700 LAKE WORTH RD | ||||||||
| Address2: | #204 | ||||||||
| City: | GREENACRES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334634727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5619687968 | ||||||||
| FaxNumber: | 5619644603 | ||||||||
| Practice Location | |||||||||
| Address1: | 2015 OCEAN DR | ||||||||
| Address2: | #8 | ||||||||
| City: | BOYNTON BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 334265131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5617374777 | ||||||||
| FaxNumber: | 5617370996 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2006 | ||||||||
| LastUpdateDate: | 02/25/2011 | ||||||||
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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 | 207R00000X | ME81999 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.