Basic Information
| Provider Information | |||||||||
| NPI: | 1780757062 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | JACOB | ||||||||
| FirstName: | GLEN | ||||||||
| MiddleName: | MIRANDILLA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2101 EAST JEFFERSON STREET | ||||||||
| Address2: | PPQA MEDICARE COMPLIANCE UNIT 6 WEST ATTN THERESA BROOK | ||||||||
| City: | ROCKVILLE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 208524908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3018166660 | ||||||||
| FaxNumber: | 3018166308 | ||||||||
| Practice Location | |||||||||
| Address1: | 1221 MERCANTILE LANE | ||||||||
| Address2: | |||||||||
| City: | LARGO | ||||||||
| State: | MD | ||||||||
| PostalCode: | 207745374 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016185578 | ||||||||
| FaxNumber: | 3016185673 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/16/2006 | ||||||||
| LastUpdateDate: | 02/23/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD034269 | DC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 9880 | NM | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RG0300X | D59633 | MD | N | Allopathic & Osteopathic Physicians | Internal Medicine | Geriatric Medicine | 207R00000X | D59633 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.