1538204326 NPI number — DR. GARY JOHN JACOBS O.D.

Table of content: DR. GARY JOHN JACOBS O.D. (NPI 1538204326)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538204326 NPI number — DR. GARY JOHN JACOBS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBS
Provider First Name:
GARY
Provider Middle Name:
JOHN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1538204326
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 E. ESPLANADE DR
Provider Second Line Business Mailing Address:
SUITE 560
Provider Business Mailing Address City Name:
OXNARD
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93036
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-485-5831
Provider Business Mailing Address Fax Number:
805-485-5657

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 E ESPLANADE DR
Provider Second Line Business Practice Location Address:
SUITE 560
Provider Business Practice Location Address City Name:
OXNARD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93036-1238
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-485-5831
Provider Business Practice Location Address Fax Number:
805-485-5657
Provider Enumeration Date:
02/20/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  6057 TPA , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: SD0060570 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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