Provider Demographics
NPI:1093759151
Name:JACOBSON, ERIC DUDLEY (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:DUDLEY
Last Name:JACOBSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 WEST STETSON AVENUE
Mailing Address - Street 2:SUITE B
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92543
Mailing Address - Country:US
Mailing Address - Phone:951-537-6002
Mailing Address - Fax:
Practice Address - Street 1:809 WEST STETSON AVENUE SUITE B
Practice Address - Street 2:APEX RADIOLOGY MEDICAL GROUP, INC
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92543
Practice Address - Country:US
Practice Address - Phone:951-537-6002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG632502085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G632502OtherMEDICARE PTAN
CA300116435OtherRAILROAD
CA00G632501OtherMEDICARE PTAN
CA300116419OtherRAILROAD
CA300116433OtherRAILROAD
CA00G632500Medicaid
CA300116419OtherRAILROAD
CAAO181ZMedicare PIN
CAWG63250AMedicare PIN
CA00G632500Medicaid