1760619910 NPI number — DANIEL M JACOBS MD PA

Table of content: (NPI 1760619910)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760619910 NPI number — DANIEL M JACOBS MD PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DANIEL M JACOBS MD PA
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1760619910
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/03/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2200 NORTH MAYFAIR ROAD
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
WAUWATOSA
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53226-2252
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
414-258-9511
Provider Business Mailing Address Fax Number:
414-607-3946

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
458 W HILLSBORO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEERFIELD BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33441-1604
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
954-895-2862
Provider Business Practice Location Address Fax Number:
414-607-3946
Provider Enumeration Date:
06/15/2009

Additional Information

Authorized Official

Authorized Official Last Name:
JACOBS
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
954-895-2862

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  800025654 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: P00921513 . This is a "RR MEDICARE" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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