1386668903 NPI number — DR. ANNAMMA J JACOB M.D.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386668903 NPI number — DR. ANNAMMA J JACOB M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOB
Provider First Name:
ANNAMMA
Provider Middle Name:
J
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1386668903
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/26/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1635 N GEORGE MASON DR
Provider Second Line Business Mailing Address:
STE 240
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
22205-3681
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-528-1329
Provider Business Mailing Address Fax Number:
703-522-4915

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1635 N GEORGE MASON DR
Provider Second Line Business Practice Location Address:
STE 240
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22205-3681
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-528-1329
Provider Business Practice Location Address Fax Number:
703-522-4915
Provider Enumeration Date:
07/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207KA0200X , with the licence number:  0101034078 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 207K00000X , with the licence number: 0101034078 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 081723 . This is a "ANTHEM" identifier . This identifiers is of the category "OTHER".
  • Identifier: 60-4923-1 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 54-1272326 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 29164 . This is a "M.D.I.P.A" identifier . This identifiers is of the category "OTHER".
  • Identifier: 8803 . This is a "CAREFIRST BLUE CROSS BLUE" identifier . This identifiers is of the category "OTHER".




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