Provider Demographics
NPI:1487633533
Name:JACOB, PREMA M (MD)
Entity type:Individual
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First Name:PREMA
Middle Name:M
Last Name:JACOB
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Gender:F
Credentials:MD
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Mailing Address - Street 1:4674 SNOW MESA DRIVE
Mailing Address - Street 2:SUITE 140
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80528
Mailing Address - Country:US
Mailing Address - Phone:970-225-5010
Mailing Address - Fax:970-482-9646
Practice Address - Street 1:3850 GRANT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-8431
Practice Address - Country:US
Practice Address - Phone:970-776-1862
Practice Address - Fax:970-482-9646
Is Sole Proprietor?:No
Enumeration Date:2006-01-16
Last Update Date:2015-11-25
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Provider Licenses
StateLicense IDTaxonomies
CO43958207Q00000X
NJ25MA04062800207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO18905072Medicaid
CO18905072Medicaid
NJD06145Medicare UPIN
COC804753Medicare PIN