1972504488 NPI number — CLYDE TYRONE JACOB III M.D.

Table of content: CLYDE TYRONE JACOB III M.D. (NPI 1972504488)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972504488 NPI number — CLYDE TYRONE JACOB III M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOB
Provider First Name:
CLYDE
Provider Middle Name:
TYRONE
Provider Name Prefix Text:
Provider Name Suffix Text:
III
Provider Credential Text:
M.D.
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:
1972504488
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/14/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5950 CABOTAGE RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30097-8475
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
908-397-2019
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6325 HOSPITAL PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNS CREEK
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30097-5775
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
678-474-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/09/2005

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: 207V00000X , with the licence number:  01089636A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 1999591 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: ME162114 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: C1-0025884 , registered in the state of DE ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 25MA09347700 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 81399 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 02219496 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".