Basic Information
| Provider Information | |||||||||
| NPI: | 1679513626 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | ABRAHAM | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4100 W 15TH ST | ||||||||
| Address2: | |||||||||
| City: | PLANO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 750935803 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 2601 W BELTLINE HWY STE 200 | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 537132319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6082872434 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 07/03/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RC0000X | ME147539 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease | 207RI0011X | ME147539 | FL | N | Allopathic & Osteopathic Physicians | Internal Medicine | Interventional Cardiology | 207RC0000X | 72513 | WI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Cardiovascular Disease |
ID Information
| ID | Type | State | Issuer | Description | 109091200 | 05 | FL | MEDICAID | 4248433 | 01 | TX | BLUE LINK | OTHER | 159752802 | 05 | TX | MEDICAID | P00257564 | 01 | TX | RR MCARE | OTHER |