Provider Demographics
NPI:1164423232
Name:JACOBSON, GERALDINE M (MD)
Entity Type:Individual
Prefix:
First Name:GERALDINE
Middle Name:M
Last Name:JACOBSON
Suffix:
Gender:F
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:PO BOX 9234
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26506-9234
Mailing Address - Country:US
Mailing Address - Phone:304-293-7227
Mailing Address - Fax:304-598-4717
Practice Address - Street 1:12902 USF MAGNOLIA DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-9416
Practice Address - Country:US
Practice Address - Phone:813-745-7365
Practice Address - Fax:813-449-8618
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA345002085R0001X
WV247032085R0001X
FLME503722085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA44316OtherWELLMARK BCBS
WV3810022378Medicaid
IA0254359Medicaid
IA44316OtherWELLMARK BCBS
IA920006753Medicare PIN
D20829Medicare UPIN
IA0254359Medicaid