1467423004 NPI number — MR. POTHEN JACOB MD

Table of content: DR. SUSAN R SLADE MD (NPI 1801848403)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467423004 NPI number — MR. POTHEN JACOB MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOB
Provider First Name:
POTHEN
Provider Middle Name:
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

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:
1467423004
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/05/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3001 EXECUTIVE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEARWATER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33762-5323
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-347-0005
Provider Business Mailing Address Fax Number:
727-541-6558

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1840 MEASE DR STE 305
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAFETY HARBOR
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34695-6605
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-796-4166
Provider Business Practice Location Address Fax Number:
727-669-5849
Provider Enumeration Date:
01/31/2006

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: 207RG0100X , with the licence number:  ME55603 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 225659 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2905049 . This is a "UNITED HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 055528200 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 08999 . This is a "BCBS FLORIDA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100013671 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1035494 . This is a "CAREPLUS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 206516 . This is a "AV MED" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9630253 . This is a "GHI" identifier . This identifiers is of the category "OTHER".
  • Identifier: 10694801 . This is a "CITRUS HEALTHCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 1200283-007 . This is a "CIGNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4248344 . This is a "AETNA" identifier . This identifiers is of the category "OTHER".
  • Identifier: 01990 . This is a "WELLCARE" identifier . This identifiers is of the category "OTHER".




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