1124023809 NPI number — DR. MARK A JACOBS O.D.

Table of content: DR. MARK A JACOBS O.D. (NPI 1124023809)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124023809 NPI number — DR. MARK A JACOBS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JACOBS
Provider First Name:
MARK
Provider Middle Name:
A
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:
1124023809
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERGUSON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
42533-0306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-492-2211
Provider Business Mailing Address Fax Number:
606-676-0873

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3810 S HIGHWAY 27
Provider Second Line Business Practice Location Address:
SUITE 1
Provider Business Practice Location Address City Name:
SOMERSET
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
42501-3073
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-678-4551
Provider Business Practice Location Address Fax Number:
606-678-0972
Provider Enumeration Date:
06/17/2005

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:  1201DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 410028407 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 380000269 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100209960 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 127554 . This is a "BCBSTN/BLUECARE/TENNCARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 4599154 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7100209970 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 00160523 . This is a "AMERIGROUP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 77012011 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com