Provider Demographics
NPI:1144338724
Name:JACOB, LALITHA E (MD)
Entity type:Individual
Prefix:
First Name:LALITHA
Middle Name:E
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 1:6229 66TH ST N
Mailing Address - Street 2:
Mailing Address - City:PINELLAS PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33781-5025
Mailing Address - Country:US
Mailing Address - Phone:727-528-1888
Mailing Address - Fax:727-528-0586
Practice Address - Street 1:6229 66TH ST N
Practice Address - Street 2:
Practice Address - City:PINELLAS PARK
Practice Address - State:FL
Practice Address - Zip Code:33781-5025
Practice Address - Country:US
Practice Address - Phone:727-528-1888
Practice Address - Fax:727-528-0586
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2011-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME622382084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250587800Medicaid
FL31517OtherBLUE CROSS
FL250587800Medicaid
G34998Medicare UPIN
FL31517AMedicare ID - Type Unspecified