Provider Demographics
NPI:1093798639
Name:JACOBS, COSMO GORDON (MD)
Entity Type:Individual
Prefix:MR
First Name:COSMO
Middle Name:GORDON
Last Name:JACOBS
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 1:4001 LIBERTY HEIGHTS AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21207-7545
Mailing Address - Country:US
Mailing Address - Phone:410-578-1100
Mailing Address - Fax:410-578-0596
Practice Address - Street 1:4001 LIBERTY HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21207-8053
Practice Address - Country:US
Practice Address - Phone:410-578-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2010-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD21328207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD791251000Medicaid
E00533Medicare UPIN
MD791251000Medicaid