Individual
DR. GLEN MIRANDILLA JACOB
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1221 MERCANTILE LANE, LARGO, MD 20774-5374
(301) 618-5578
(301) 618-5673
Mailing address
2101 EAST JEFFERSON STREET, PPQA MEDICARE COMPLIANCE UNIT 6 WEST ATTN THERESA BROOK, ROCKVILLE, MD 20852-4908
(301) 816-6660
(301) 816-6308
Taxonomy
Speciality
Code
Description
License number
State
207R00000X
Internal Medicine Physician
9880
NM
207R00000X
Internal Medicine Physician
Primary
D59633
MD
207R00000X
Internal Medicine Physician
MD034269
DC
207RG0300X
Geriatric Medicine (Internal Medicine) Physician
D59633
MD
Other
Enumeration date
11/16/2006
Last updated
02/23/2022
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