Provider Demographics
NPI:1053300913
Name:JACOBS, MICHAEL B (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:B
Last Name:JACOBS
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3017 WEST CHARLESTON BLVD
Mailing Address - Street 2:SUITE 60
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89102-1927
Mailing Address - Country:US
Mailing Address - Phone:702-778-5100
Mailing Address - Fax:702-778-5101
Practice Address - Street 1:3017 W CHARLESTON BLVD
Practice Address - Street 2:SUITE 60
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89102-1927
Practice Address - Country:US
Practice Address - Phone:702-778-5100
Practice Address - Fax:702-778-5101
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9037207R00000X
NY243291207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV880454631OtherTAX ID NUMBER
NVE-65246Medicare UPIN
NVV33727Medicare PIN