Provider Demographics
NPI:1124013883
Name:JACOBS, MARK D (MD)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
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 1:100 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02494-2809
Mailing Address - Country:US
Mailing Address - Phone:781-726-4800
Mailing Address - Fax:
Practice Address - Street 1:100 2ND AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02494-2809
Practice Address - Country:US
Practice Address - Phone:781-726-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA242029207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANPIOther1124013883
MA9239986OtherCIGNA
MA9971374OtherAETNA
MA242029OtherMEDICAL LICENSE
MA404478OtherTUFTS HEALTH PLAN
MAAA173484OtherHPHC
MA001500001Medicare PIN