Provider Demographics
NPI:1538156963
Name:JACOB, STUART (DPM)
Entity type:Individual
Prefix:DR
First Name:STUART
Middle Name:
Last Name:JACOB
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 W BROAD ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08016-1343
Mailing Address - Country:US
Mailing Address - Phone:609-386-0217
Mailing Address - Fax:609-386-2205
Practice Address - Street 1:319 W BROAD ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NJ
Practice Address - Zip Code:08016-1343
Practice Address - Country:US
Practice Address - Phone:609-386-0217
Practice Address - Fax:609-386-2205
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2009-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00189200213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223483019OtherPALMETTO RAILROAD MEDICAR
0099360000OtherINDEPENDENCE BLUE CROSS PERSONAL CHOICE
NJ6324401Medicaid
NJJ013907OtherTRICARE
0099360000OtherINDEPENDENCE BLUE SHIELD
NJ223483019OtherHORIZON
223483019OtherINDEPENDENCE BLUE
NJ4146690001OtherDME REGION A
NJBNS146OtherOXFORD
NJ000781126001OtherUNITED HEALTHCARE
NJ6111499OtherCIGNA
NJ0099360000OtherAMERIHEALTH
NJ0183361OtherAETNA
NJJ013907OtherTRICARE
NJ6324401Medicaid