Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 204C00000X | Sports Medicine Doctor | ME0054778 | FL |
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | ME0054778 | FL |
NPI | 1750310215 |
---|---|
Provider Name | Dr. Eacharangad Ipye Jacob |
First Address | Panama City, FL 32401-3611 |
Second Address | Panama City, FL 32401-3611 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 30/06/2006 |
Last Update Date | 30/07/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
035463500 | (05) | FL |
E22886 | (02) | FL |