Provider Demographics
NPI:1578631511
Name:JACOB, NIRMALA ROSE (MD)
Entity type:Individual
Prefix:DR
First Name:NIRMALA
Middle Name:ROSE
Last Name:JACOB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 LUCIEN WAY STE 100
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7003
Mailing Address - Country:US
Mailing Address - Phone:407-875-0028
Mailing Address - Fax:
Practice Address - Street 1:2201 LUCIEN WAY STE 100
Practice Address - Street 2:
Practice Address - City:MAITLAND
Practice Address - State:FL
Practice Address - Zip Code:32751-7003
Practice Address - Country:US
Practice Address - Phone:401-875-0028
Practice Address - Fax:888-258-2307
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME75726207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL277885800Medicaid
FLP01139623OtherRR MCR
FLH04165Medicare UPIN
FL43654UMedicare PIN
FLP01139623OtherRR MCR