Provider Demographics
NPI:1164495693
Name:JACOBS, MICHAEL SCOTT (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:SCOTT
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 1:1080 VEND DR STE 100
Mailing Address - Street 2:
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-7751
Mailing Address - Country:US
Mailing Address - Phone:706-549-7047
Mailing Address - Fax:706-613-5395
Practice Address - Street 1:1080 VEND DR
Practice Address - Street 2:SUITE 100
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-7751
Practice Address - Country:US
Practice Address - Phone:706-549-7047
Practice Address - Fax:706-613-5395
Is Sole Proprietor?:No
Enumeration Date:2006-02-07
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA053926207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA220660534Medicaid
GAP00131029OtherRAILROAD RETIREMENT
GA18BDGHKMedicare ID - Type Unspecified
GAP00131029OtherRAILROAD RETIREMENT